DISCHARGE SUMMARY

DEPARTMENT OF INTERNAL MEDICINE

POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION AND RESEARCH
CHANDIGARH – 160 012 (INDIA)

NAME Rajinder kaur Age/ Sex 53 years/F C.R. No. 202205154409

Father/Husband Binder singh DOA 5/12/2022 Admission No 2022090271
Consultant Dr. Ashish Bhalla DOD 12/12/2022 Phone No 9132991328

Diagnosis Amoebic Left lobe liver abscess

Status post percutaneous drainage (6/12/22 to 12/12/22)
Coagulopathy (corrected)
Cholelithiasis
Hyponatremia
Hypothyroid
Dimorphic anemia

Chief Complains:

Pain abdomen for 1month

Fever x 1week

HOPI:

Patient had history of attending a marriage 1 month back, next day following which she developed complaints of pain
abdomen, loose stools, and vomiting.

Loose stool - 4 episodes/day, watery, small amount, associated with tenesmus, not associated with any blood or mucus,
resolved with medication in one day

Vomiting - 3 episodes, containing food particles, non-projectile, non-bloody or nonbilious, resolved with medication in 1
day.

Pain abdomen at right upper quadrant – gradual onset, progressive, dull aching, initially mild, increased after food intake
non-radiating, increased in severity since last 1 week, requiring painkiller. Patient also gives H/O abdominal massage
following which the pain became severe, requiring IV medication.

Patient also complaints of fever since last 1 week - acute onset, high grade, undocumented, associated with chills,
continuous, no diurnal variation, relieved temporarily with medication, not a/w rash/ bodyaches/joint pains.

H/O decreased oral intake since last 1 month.

No history of jaundice, abdominal distension.

No history of chest pain, cough, SOB, palpitation, PND

No history of burning micturition, decreased urine output, hematuria.

No history of bleeding from any site,

No history of AMS, LOC, seizure

TREATMENT HISTORY-

With these symptoms, gone to local private hospital 1 day prior to admission in PGI, where given intravenous injection,
fluids, antibiotics and after CECT assessment shown to have liver abscess sent to PGIMER.

Past history

Known hypothyroid for last 5 years, on Thyronorm 75 microgram.

No history of DM, hypertension, CAD, CVA, COPD, BA.

Personal h/o:
veg diet.
Sleep Normal.
Decrease appetite
Bowel and bladder normal
No h/o any addictions.
Menopause at 45 years

Family history:

No significant h/o similar or any other illness in the family

EXAMINATION:
GENERAL EXAMINATION SYSTEMIC EXAMINATION

Patient is conscious, alert, cooperative Abdomen:

well oriented to time, place, and Inspection-
person. Abdomen distended; flanks full
GCS: E4V5M6 Umbilicus midline inverted
BMI 23.6 All quadrants moving equally with respiration
On admission: No scars, visible pulsation or peristalsis or dilated veins

BP:132/82 mm Hg Palpation-
PULSE:82/min, regular, good volume, Superficial- nontender, temperature normal
no RR or RF delay, vessel wall not Deep -
palpable Liver margin palpable 2 cm below RCM at MCL,
RR:18/min, abdomino-thoracic smooth rounded surface, soft consistency, moves with respiration,
Sp02: 96% @ RA Able to insert finger under costal margin, Liver span 11 cm
Temperature: afebrile Spleen non palpable
-
P+I- C C- L-E-
Percussion-
JVP not raised No shifting dullness

Auscultation-
Skin normal Bowel sounds- 10-12/min
hair, and nail normal No bruit or venous hum

RS:
Trachea central.
B/L NVBS present.
No added sound

CVS:
S1S2 Normal; No S3 or murmur.
 CNS:
E4M6V5
Higher mental functions normal
No FND
Bilateral pupil NSNR
Sensory: intact
Power: Bilateral UL- 5/5
Bilateral LL- 5/5
Tone: UL- normal
LL- normal.
DTR:
Biceps: 2+
Triceps: 2+
Supinator: 2+
Knee: 2+
Ankle: 2+

B/L plantar flexor.

INVESTIGATIONS:

Date 5/12/22 7/12/22 9/12/22 12/12/22

HB 9.3 10.7 10.4 10.3

TLC 7000 11200 9400 10800

PLT 302 k 383 k 450k 530K

SE 131/3.36/94.6 129/3.5/93 129/4.1/94 129.5/4.3/93

RFT 32.2/0.84 25.7/0.77 15/0.7 19.8/0.98

TP/Alb 6.8/2.96 7.5/3.77 7.3/3.4 7.5/0.14

B(T/C) 0.16/0.13 0.15/0.06 0.2/0.1 0.1/0.06

OT/PT/ALP 89/103/100 17/22/106 16/14.4/90 19/15/78

Ca/PO4/Mg 8.53/2.28/1.82 8.3/2.4/- 8/3/-

PT/PTI 17.9/77%

INR/APTT 1.28/27.2

CRP 54.50 43.76 12.6 4.8

LDH 185 186 169

OTHER INVESTIGATION-

SEPSIS WORK UP -

Procal 0.222 6/12/22

blood c/s sterile 7/12/22

urine c/s sterile 7/12/22

urine RME Albumin negative 7/12/22

Sugar negative
Other normal

PUS culture sterile 7/12/22

ANAEMIA WORK UP -

VIT B12 234 6/12/22

FOLATE 4 6/12/22

PBF mild anisocytosis 6/12/22

Normocytic normochromic red cells
Platelets adequate

Iron profile iron level 18.9 7/12/22

UIBC 224.4
TIBC 243.3
%SATURATION 7.77
FERRITIN 274

TROPICAL FEVER WORK UP -

Leptospira IgM negative 7/12/22

widal Negative 6/12/22

malaria Ag Negative 6/12/22

dengue NS1Ag Negative 6/12/22

scrub typhus IgM Positive 0.499(>0.468) 6/12/22

HYDATID AND AMOEBIC WORK UP -

Hydatosis IgG Negative 6/12/22

 Stool RME Normal 7/12/22
Amoebic serology(IgG) positive 7/12/22

THYROID WORK UP -

TSH 1.63 6/12/22

T4 6.81 6/12/22

T3 0.458 6/12/22

VIRAL MARKERS WORK UP -

HIV negative 6/12/22

HBsAg negative 6/12/22

HCV Ag negative 6/12/22

DIABETIC WORK UP -

HBA1c 5.7 6/12/22

HYPONATRAEMIA WORK UP (12/12/22)

Osmolarity (serum) 282

Osmolarity (urine) 615
ACTH/Cortisol 30/466

USG ABDOMEN (4/12/22)

Liver 12.5cm, fatty infiltrations grade I/II, hypodense lesion 6.2*3.4cm, noted in segment IV with no internal vasculature
Spleen- 8.6cm
GB partially distended with multiple small calculi in lumen largest 7mm s/o Cholelithiasis
RK 9.2cm, LK 9.6cm, CMD and cortical echogenicity normal

CECT abdomen and pelvis (3/12/22)(outside)

Fatty infiltration of liver. peripherally enhancing hypodense lesions/collections measuring approx. 4.68*3.4cm and 2*1.8
cm noted in left lobe of liver likely hepatic abscess.
Cholelithiasis without changes of cholecystitis
Mild bilateral pleural effusion

COURSE AND MANAGEMENT:

With these above symptoms patient presented EMOPD were started with intravenous fluids and Inj. ceftriaxone and Inj.
Metronidazole and routine work up sent. In view of deranged coagulation profile at admission, 6 FFP were transfused which
was followed by PCD insertion on 6/12/22. Frank pus came out on aspiration and sent for work up. On first day around
300ml pus drained later decreased to minimal drainage. Patient gradually improved and appetite improved and became
afebrile. All work up came back negative. Reassessment for collection done on 9/12/22 shown to have minimal collection
and advised for active aspiration for 3 days which did not yield any aspirate. On 12/12/22 review IR assessment shown to
have 1.5*2.5 cm organized collection at left lobe but no active aspirate, so PCD removed. Inj. Ceftriaxone stopped on
completion of 7 days antibiotic. Patient afebrile for 5days and vitals stable so discharged with advice written in discharge
booklet , to follow up at ID OPD on Monday.

Advise on discharge:

As described in the booklet.

Consultant Prof Ashish Bhalla, Dr Vikas Suri, Dr Ritin Mohindra, Dr Harpreet Singh

Senior Resident Dr Anureet

Junior Resident Dr Souresh, Dr Chandra Mohan