20-01-2023
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
PATIENT HISTORY: Patient is a 52yr old male doing business supplying small machine parts.
At the age of 12yrs, he c/o anorexia, incomplete evacuation of stool, and acidity. He was taken to a local doctor who detected hepatomegaly and prescribed medications, taking which resolved his symptoms within a few days.
At the age of 13, he c/o high fever (103-104F), headache, and general body weakness lasting for 3-4 days, resolved with medications. 2 yrs later it happened again.
In 2020, one day when he went to a function, where he ate lot of fries, chicken and sweets. After returning home at night he started c/o localised intense pain in the right upper quadrant. The pain was increasing as the night progressed and taking medication for gas did not help. The next day his pain became unbearable and got admitted in a hospital, wherein he was injected with medication to relieve the pain. His pain reduced slowly. USG was done which detected Gallstone.
He went to a doctor who did a Laparoscopic Cholecystectomy. He had no complaints after that.
In 2022 he c/o localised mild pain inupper right quadrant. Initially the pain would occur at any time of the day 1-2 times daily and would last 10-15 mins. Mostly after dinner when he went to sleep and in a supine position. On tossing and turning to either side slowly the pain would disappear after 10-15 mins. For the past few weeks the pain occured 4-5 times a week. Doctor prescribed paraetamol which reduced pain temporarily. Then USG and CT abdomen were done which revealed a liver abscess. Doctor performed USG guided Percutaneous drainage, but during a follow up, doctor told there had been not much improvement and he would need a laparoscopic drainage of liver abscess. He didn't go for any further consultation.
Patient reported for the past few months he is passing brown greasy stools.
For the past 15-20 days, he is experiencing incomplete evacuation of stools.
After being diagnosed with a liver abscess he lost 4-5 kgs of weight which he regained in the past few months.
Patient denied any history of HTN or DM.
ADDICTION: He started eating paan with tobacco in it at the age of 17 yrs. Used to have 10-15 times daily. After being diagnosed with Liver Abscess he eats 1-3 times daily.
CHIEF COMPLIANTS AND PATIENT REQ:
1. Pain in the right quadrant of abdomen for the past 10 months
2. C/O incomplete evacuation of bowel for the past 20 days.
FAMILY HISTORY:
Father - C/O loose motions, sudden urge to defecate, BPH
Mother - Death due to stage 4 gallbladder Ca.
Before USG guided aspiration, he used to c/o burning sensation in the smaller circle area.
BELOW ARE THE REPORTS:
PROVISIONAL DIAGNOSIS: LIVER ABSCESS.
[30-05-2025 11:22] PPM 1: Today's update from the patient advocate (after nearly 2 and a half years)!:
Goto 3/2/23 Kims hospital admission hoi abong liverar pasa akta absage chilo tar oparation hoy akhon abar liverar ariata batha korche abong vari vari lagcha kichu khata parina hatachala korta khub porisrom hoy ki korbo sir. Nicha USG riport dilam.
[30-05-2025 11:27] PPM 1: Will need to pull out his EMR summary from 3/2/23 to understand what happened here at that time
[31-05-2025 12:35] PPM 1: @CR here's his EMR summary. Please go ahead and prepare the mirror case report with the previous data from @PPM3 (who I'm sure had his consent form and can pm it to us) and this EMR summary data from 2023 followed by latest update where he says he has recently again developed certain symptoms of anorexia and pain in the right hypochondrium as before and a repeat USG also shows the old abscess
Age/Gender: 58 Years/Male
Address
Discharge Type: Relieved
Admission Date: 03/02/2023 11:45 AM
Date of Operation
10/02/2023
RIGHT SUBPHRENIC Abscess CORRESPONDING TO 6TH AND 7TH SEGMENT OF LIVER PUSHING THEM MEDIALLY, ABSCESS OPERATED BY EXPLORATORY Laparotomy UNDER GENERAL ANAESTHESIA.
17/02/2023
SECONDARY SUTURING UNDER LA FOR POST OPERATIVE SURGICAL SITE INFECTION.
Diagnosis
RIGHT SUBPHRENIC ABSCESS CORRESPONDING TO 6TH AND 7TH SEGMENT OF LIVER PUSHING THEM MEDIALLY
Case History and Clinical Findings
C/O PAIN ABDOMEN (RIGHT UPPER QUADRANT) SINCE 6 MONTHS.
HOPI- PATIENT WAS APPARENTLY ASYMPTOMATIC 3 YEARS BACK, THEN HE DEVELOPED DULL ACHING PAIN IN RIGHT UPPER ABDOMEN WITH NO AGGREVATING OR RELIEVING FACTORS.
NO H/O VOMITINGS/CONSTIPATION PAST HISTORY :
AT AGE 12 DETECTED HEPATOMEGALY.
IN 2020 DIAGNOSED WITH CHOLELITHIASIS, THEN LAPAROSCOPIC CHOLECYSTECTOMY WAS DONE.
IN 2022 C/O LOCALIZED MILD PAIN IN UPPER RIGHT QUADRANT. USG ABDOMEN REVEALED LIVER ABSCESS, USG GUIDED ASPIRATION OF RIGHT SUBPHRENIC ABSCESS DONE IN JULY 2022
KNOWN CASE OF LIVER ABSCESS SINCE 7 MONTHS NOT A KNOWN CASE OF DM, HTN, TB, EPILEPSY, CVA. GENERAL EXAMINATION:
VITALS:
TEMP: AFEBRILE PR: 82 BPM
RR: 16 CPM
BP: 130/90 MM HG
P/A: SOFT, NONTENDER, NO GUARDING, NO RIGIDITY, BOWEL SOUNDS PRESENT
Investigation
USG (07/02/23) -
MILD ATROPHIC FUNDAL GASTRITIS CT ABDOMEN AND PELVIS -
-GALL BLADDER POST OPERATIVE STATUS.
-SUB PHRENIC COLLECTION MEASURING 8.5X4.8X6.7 cm (CCXTXAP) ON RIGHT SIDE CAUSING COMPRESSION AND MEDIAL DISPLACEMENT OF SEGMENT V AND VI OF LIVER.
-FEW WELL DEFINED RADIO OPACITIES FLOATING WITHIN THE COLLECTION.
-SPILLED GALL STONES WITH SUB PHRENIC COLLECTION.
Treatment Given (Enter only Generic Name)
INJ. MONOCEF 1GM/IV/TWICE DAILY
INJ. METROGYL 500 MG IV/ THRICE DAILY INJ. AMIKACIN 500MG/IV /BD
INJ. PAN 40MG/IV/ONCE DAILY
INJ. TRAMADOL 1 AMPUL IN 100ML NS/SLOW IV/ SOS INJ. OCM 1GM/IV THRICE DAILY
INJ. ZOFER 4MG/IV/SOS
T. PAN 40MG P/O TWICE DAILY
T. ULTRACET P/O TWICE DAILY
T. CHYMORAL FORTE P/O THRICE DAILY (BEFORE FOOD)
T. SERAX FORTE 20 MG P/O THRICE DAILY
T. MVT P/O ONCE DAILY
STEAM INHALATION 8TH HOURLY PROTEIN DIET
Advice at Discharge
HIGH PROTEIN DIET (2 EGG WHITES/MEAL)
T. CIPROFLOXACIN 200MG P/O TWICE DAILY FOR 7 DAYS
T. PAN 40MG P/O ONCE DAILY, 30MINS BEFORE BREAKFAST FOR 7 DAYS
T. ACYCLO -P TWICE DAILY FOR 7 DAYS
T. CHYMEROL FORTE P/O THRICE DAILY BEFORE FOOD FOR 5 DAYS
T. SERAX FORTE 20 MG P/O THRICE DAILY (AFTER FOOD) FOR 5 DAYS
T. MVT P/O ONCE DAILY FOR 10DAYS
T. VIT C P/O ONCE DAILY FOR 10 DAYS
PROTEIN POWDER 2 TSPS IN 1GLASS WATER/MILK THRICE DAILY FOR 10 DAYS
Follow Up
REVIEW TO SURGICAL OPD (46) FOR SUTURE REMOVAL AFTER 1 WEEK
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration: - The medicines prescribed and the advice regarding preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date: 23/02/2023 Ward: MSW
Unit: V
[02-06-2025 11:18] PPM 1: Update:
[31/05, 09:45]pm: Bortoman somosya guno kabe theke ter peyechen?
[31/05, 18:22] Pt 52M Cholelith Abscess: 9/5/25 thaka halka batha abong vari vab suruhoy
[31/05, 18:28]pm: 9/5/25 theke aekhon obdhi are ki ki hoyeche
[02/06, 11:02] Pt 52M Cholelith Abscess: Local doctor Deva medicine kachi kintu akhon batha korche. Shorir akhon no durbol. Aktu khani jayega hatte parina . Pete jhanki lagale baitha Lage.
[02/06, 11:05] Pt 52M Cholelith Abscess: Rater belay besi bethakore .
[02-06-2025 12:21] PPM 3: Based on this abdominal ultrasound report, here's a clear breakdown of the findings and recommended next steps:
*Key Findings & Interpretation:*
1. *Liver:*
* *Fatty Liver (Grade II):* Confirmed diffuse fatty infiltration. This is common and often related to metabolic factors (obesity, diabetes, high cholesterol) or alcohol.
* *Significant Mass Lesion:* A large (88 x 55 x 67 mm ≈ 8.8 x 5.5 x 6.7 cm), lobulated, hypoechoic (dark on ultrasound), inhomogeneous mass in the right lobe, near the edge (subcapsular). The report suggests two main possibilities:
* A *tumor/mass lesion* (needs urgent characterization).
* An *organized old abscess* (a healed or chronic infection pocket).
* *Bile Ducts & Portal Vein:* Normal appearance (IHBR = IntraHepatic Bile Radicles, PV = Portal Vein).
2. *Gallbladder:*
* *Absent (Post-cholecystectomy status):* As expected from prior surgery.
3. *Common Bile Duct (CBD):*
* *Normal:* Mildly dilated (4.9 mm is within normal limits), no blockage seen.
4. *Pancreas, Spleen, Kidneys, Ureters, Urinary Bladder:*
* *All Normal:* No significant abnormalities detected in size, structure, or appearance.
5. *Prostate:*
* *Mild Enlargement (Grade I):* Size is slightly increased (26.7 cc; normal is usually <25-30 cc for age, but varies), but texture and capsule appear normal. This is common with aging (Benign Prostatic Hyperplasia - BPH).
6. *Abdominal Wall:*
* *Sinus Track:* A linear, hypoechoic (fluid-filled) track (20mm x 7mm) in the upper central belly (epigastric region). This suggests a potential abnormal connection/tunnel, possibly related to prior surgery/infection.
7. *Lymph Nodes & Fluid:*
* *No Ascites or Obvious Lymphadenopathy:* No free fluid in the abdomen or significantly enlarged lymph nodes seen.
*Summary (Impression):*
1. *Grade II Diffuse Fatty Liver Infiltration.*
2. *Large Lobulated Mass in the Right Liver Lobe:* Critical finding requiring urgent further investigation to differentiate between a possible tumor or an organized old abscess.
3. *Status Post Gallbladder Removal.*
4. *Sinus Track in Epigastric Abdominal Wall.*
5. *Grade I Prostate Enlargement (Benign).*
*Urgent Recommendations:*
1. *Further Liver Mass Evaluation:* *This is the most critical finding.* An ultrasound cannot definitively diagnose the nature of this large mass.
* *Contrast-enhanced CT scan (CECT) or MRI of the liver* is *ESSENTIAL* to characterize the mass (tumor vs. abscess vs. other) and determine the next steps (biopsy, treatment planning).
* Liver function tests (LFTs) and tumor markers (like AFP) may also be requested by your doctor.
2. *Fatty Liver Management:* Address underlying causes:
* Weight loss (if overweight).
* Control blood sugar (if diabetic/pre-diabetic).
* Control cholesterol/triglycerides.
* Regular exercise.
* Avoid alcohol.
3. *Sinus Track Evaluation:* Needs clinical examination by your doctor/surgeon to determine the cause (e.g., related to prior surgery?) and if any treatment (like antibiotics or drainage) is required.
4. *Prostate:* Mild enlargement is typically monitored. If urinary symptoms exist, discuss them with your doctor.
5. *Clinical Correlation:* Discuss all these findings thoroughly with your treating physician. Bring any relevant history (past infections, liver issues, abdominal surgeries beyond gallbladder, symptoms like pain, fever, weight loss, jaundice) as this is crucial for interpreting the scan and planning management.
*In summary: The fatty liver and prostate enlargement are common findings requiring lifestyle management/monitoring. The liver mass is a serious concern needing immediate further imaging (CT/MRI), and the sinus track needs clinical assessment.* Please schedule an appointment with your doctor promptly to review this report and initiate the necessary investigations.[DeepSeek]
No comments:
Post a Comment