A 32 yr old male came with the complaints of fever since 1 week


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 32 yr old male came with the complaints of fever since 1 week 
HOPI 
Patient was apparently asymptomatic 1 week back and then developed fever which was sudden in onset gradually progressive high grade associated with chills and generalised weakness for which he went to local RMP and took medication for 2 days still the symptoms didnot subside and further investigation like blood test done and his blood sugars were 300mg/dl 
As the symptoms didnot subside they went to Miryalguda hospital there USG was done and impression showed HEPATIC ABSCESS 
and refered to our hospital 
Patient came to hospital yesterday and USG was done impression showing: 
NO H/o vomitings 
No h/o cough cold diarrhoea 

Past history: 
K/c/o DM type 2 since 2 months and was on metformin hydrochloride
N/kc/o HTN TB Epilepsy BA 
 Personal history: 
Diet mixed 
Appetite normal 
Sleep Adequate
Bowel decreased since 3 days and passed stools yesterday 
Bladder movements are regular 
Addictions: occasional alcohol consumption since 5 years but stopped consumption from 2 months 
Occasionally smoker since 5 years 

General examination

Pat is c/c/c well oriented to time place person 

He is moderately built and nourished

No signs of pallor icterus cyanosis clubbing lymphadenopathy generalized edema
Vitals 

Temperature - 102 F 

BP - 110/70 mm hg 

PR - 86 BPM 

RR - 16 cpm 

Systemic examination

CVS - S1 S2 Heard no murmurs 

RS - BAE + NVBS 

CNS : NFND 

PER ABDOMEN EXAMINATION:

Inspection:

Shape of the abdomen:Distended 

Flanks:Free 

Umbilicus:center,oval shape 

Skin-normal,no sinuses,scars,striae 

No dilated viens 

Abdominal wall moves with respiration 

No hernial orifices 

Palpation:

No local rise of temperature,no tenderness.All inspectory findings are confirmed by palpation. 

Liver:Not palpable,Non tender,no hepatomegaly

Spleen:Not palpable,non tender,no splenomegaly 

Kidney:Non tender and not palpable 

No other palpable swellings 

Percussion: 

On abdomen percussion tympanic note is heard

Liver span:12cms in mid clavicular line 

Spleen:No dullness is heard 

USG DONE on 7/10/23 

Impression: Hepatic abscess of size 9x7cm noted in 5 and 6 segments of liver with 20% liquefaction.

PROVISIONAL DIAGNOSIS:  

HEPATIC ABSCESS 

K/C/O DM TYPE 2 


INVESTIGATIONS: 






TREATMENT: 

Inj.NEOMOL 1G IV STAT 

Inj.MAGNEX FORTE 1.5GMS IV STAT 

Inj.METROGYL 500MG IV TID 

Inj.PAN 40MG IV/OD 

IV FLUIDS - NS RL 

Tab.DOLO 650MG PO/SOS 

TEPID SPONGING

Comments

Post a Comment

Popular posts from this blog

Image
70 year old male with  1)fever since 15 days 2)generalised weakness and body pains  in bilateral lower limbs since 10  days HOPI Pt was apparently asymptomatic 15 days back then had fever which high grade more during night time associated with chills and rigors it is intermittent not associated with cold , cough, vomitings , loose motions, abdominal pain, burning micturition , no h/o rash, hematuria, bleeding from gums For which he was taken to local rmp and  got treated for the same and diagnosed typhoid fever and reports from outside showing platelets of 85,000 Then he had generalised body weakness and  pains in bilateral lower limbs and lower back ache since 3days. Pt is unable to walk or stand without support since 3 days DAILY ROUTINE He wakes up at morning 6 does his daily routine and takes rice at 8:00-9:00am goes to work ( farmer)  and takes food at 1:00pm returns home at 5:00 pm and takes dinner at 8:00pm qnd goes to sleep PAST HISTORY   not a known case of HTN ,DM ,ASTHMA, EP
Read more

A 53 year old came to casuality with C/o pedal edema since 2 months. C/O SOB Since 1 day. C/O decreased urine output since 2 months.

Image
A 53 year old male came to casualty with chief  C/o pedal edema since 2 months C/O SOB Since 1 day C/O  decreased urine output since 2 months. History of presenting illness:- Patient was apparently alright 1 year back then  he developed  decreased urine output for which he went to hospital and  was diagnosed as chronic kidney disease and was on Conservative management.  Patient  developed decreased urine output since 2 months. No  Hesitancy, dribbling of urine. -History of pedal edema Since 2 months, pitting type upto knee. -History of SOB since 1 day; Grade -IV according to MMRC  , Orthopnea present, no   PND. No chest pain, no palpitations.  3. HISTORY OF PAST ILLNESS K/c/o Dm-ll Since 7 years on insulin K/c/o HTN Snce 1 year on CILNIDIPINE 10mg. No history of asthma ,tuberculosis ,epilepsy  Personal history:  Diet mixed  Appetite normal  Sleep Adequate Bowel are regular Bladder movements decreased output since 2 months. Addictions:  Alcohol - regular but stopped since 2 years Smokin
Read more

34 year old male with vomiting, hiccups and cough.

Image
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcaaome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of i
Read more