26yr male with Rt lower zone consolidation & Liver abscess

26 year old male, construction worker by occupation presented to the casualty with the chief complaints of 

Fever since 3 months 

Cough with expectoration since 2 months 

Dyspnea on exertion since 2 months 

Vomiting since 2 months 

Decreased appetite and weight loss over last 2 months 

Dark coloured stools since 2 weeks 

History of presenting illness:-

Patient was apparently asymptomatic 3months back till when he attended his relative function where he consumed alcohol for 2days ( Around 8 beers) following which after 2days he developed high grade fever though not associated with chills & rigors or Night sweats and it subsided with medication for 1 week but from then he's having on & off fever. 

The following month he started experiencing productive cough with mucoid expectoration, blood tinged amounting to 2 to 3 cup's per day it's foul smelling . 

He also started feeling difficulty in breathing on walking for small distances . It's progressive & currently he has to take a break After walking for some distance at his own pace. 

He's having 2 to 3 episodes of vomiting daily containing food particles. 

He also complains of loss of appetite and unintentional weight loss of around 10 kgs over the past 3 months from 72kgs to 62kgs.

History of black colour stools since 2weeks not associated with mucus or foul smelling. 

No h/o chest pain, palpitations, syncopal attacks, profuse sweating, Orthopnea or paroxysmal nocturnal dyspnea

No h/o Headache, seizure, weakness of arms or legs

No h/o Regurgitation of food or epigastric burning pain. 

Past history:-

Not a k/c/o Hypertension, Diabetes mellitus, Asthma, epilepsy, Tuberculosis or any heart diseases. No past history of allergies or surgeries. 

Personal history:-

Diet- mixed

Appetite- decreased

Sleep-adequate

Bowel & bladder- normal

Occasional alcoholic, Occasional smoker. 

Family history:-

No h/o similar complaints in family members

Drug history:-

Patient visited around 4 hospitals in past three month's where he's given multiple antibiotic injections, Antipyretics.. Etc

No h/o any drug allergies . 

Summary at end of history:-

A 26yr old male who's a construction worker by occupation and who's an occasional smoker presented with persistent fever, cough with blood tinged expectoration and decreased appetite associated with weight loss since 2months and black color stools since past 2weeks and had a history of reccurent hospital visits & intake of medications for these complaints in past 2months with no history of Hypertension, diabetes or any contact with TB. 

Differentaial diagnosis:-

Lung consolidation

Lung abscess

General physical examination:-

Patient conscious, coherent, cooperative

Moderately built & moderately nourished. 

Height-

Weight-

BMI-

Temperature - 100.6f

PR - 94bpm, Regular & normal volume

BP - 100/70mmhg

RR - 24 cpm

Spo2 at 98 % on room air. 

Pallor +nt

Icterus -nt

Cyanosis -nt

Clubbing -nt

Lymphadenopathy -nt

Edema -nt

No Nicotine staining over hand's, lips or any visible wasting of hand muscles

Spine appears normal 

SYSTEMIC EXAMINATION:-

RESPIRATORY SYSTEM- 

Patient examined in sitting position

Inspection:-

Upper respiratory tract - oral cavity, nose & oropharynx appears normal. 

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements equal on both sides

Trachea central in position & Nipples are in 4th Intercoastal space

No signs of volume loss

No dilated veins, scars, sinuses, visible pulsations. 

Palpation:-

All inspiratory findings confirmed

Trachea central in position

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line

Cricosternal distance is 3finger breadths. 

MEASUREMENTS-

chest circumference-

Chest expansion-

                                         Right left

Hemithorax-

Hemithorax expansion-

Spinoscapular

Distance-

AP diameter-

Transverse diameter-

Respiratory movement's:-

Tactile vocal phremitus-

Percussion:-

                                       Right left

Supraclavicular- Resonant (R) (R) 

Infraclavicular- (R) (R) 

Mammary- (R) (R) 

Axillary- (R) (R) 

Infra axillary- Dull (R) 

Suprascapular- (R) (R) 

Interscapular- (R) (R) 

Infrascapular- Dull (R) 

Auscultation:-

                                      Right Left

Supraclavicular- Normal vesicular (NVBS)

                        Breath sounds (NVBS) 

Infraclavicular- (NVBS) (NVBS)

Mammary- (NVBS) (NVBS)

Axillary- (NVBS) (NVBS)

Infra axillary- Decrease (NVBS)

                         vesicular B.S                                    

Suprascapular- (NVBS) (NVBS)

Interscapular- (NVBS) (NVBS)

Infrascapular- Decrease (NVBS)

                           Vesicular B.S       

 ABDOMEN :-

 Inspection :

shape of abdomen appear normal & symmetrical 

No Generalised/Localised distension seen. 

All quadrants moving equally with respiration 

 Umblicus is central & inverted

Skin over the Abdomen- Looks normal 

 No visible Scars/Sinuses/Dilated/Prominent veins / peristalsis/Pulsations . 

Palpation :

All Inspectory findings confirmed 

 Mild Tenderness in right hypochondrium

No Guarding/ Rigidity 

 Edge of liver is palpable on deep inspiration Spleen is not palpable 

Percussion:-

Liver span is 15cm from right 4th ICS to right coastal margin along mid clavicular line

Spleenic dullness noticed in left coastal margin

Auscultation:-

Normal bowel sounds heard, no renal bruit heard. 

CARDIOVASCULAR SYSTEM:-

Apical Impulse felt in left 5th ICS, no parasternal heave or precordial bulge felt

S1S2 heard

No murmers heard. 

CENTRAL NERVOUS SYSTEM:-

Higher mental functions intact 

No FND, pupils-NSRL. 

DIAGNOSIS:-

Right lung lower lobe abscess.