A 40 year old male with fever and pain abdomen

MEDICINE CASE DISCUSSION

This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

A 40 YEAR OLD MALE WITH PAIN ABDOMEN AND FEVER

A 40 year old male came to casuality with chief complaints of pain abdomen and fever since 10 days.

History of present illness-
Patient was apparently asymptomatic 10 days ago,then he developed pain abdomen since 10 days which is in right upper quadrant,which is gradual ,progressive , pricking type,increased with movement,relieved with medications.
History of fever since 10 days ,which is low grade,intermittent,not associated with chills,relieved with medications.
No h/o Sob,icterus,pedal oedema,decreased urine output, abdominal distension,vomitings,cough,sore throat,trauma,weight loss,anorexia.

Past history- not a k/c/o dm,htn,asthma,epilepsy,cad,tb.


Treatment history- not significant

Personal history-diet- mixed
Appetite- normal
Sleep- adequate
Bowel and bladder- regular
Addictions-regular alcoholic,drinks quarter per day ,cigarette smoker-4/ day

Family history-Not significant

General examination-
Vitals-
Temp- afebrile
Pr-98/min
Rr-21/min
Bp-110/70 mm hg
Spo2-98% at ra

There is no pallor,icterus,cyanosis,clubbing,lymphadenopathy.

Neck,arms and legs are normal 

Systemic examination-

Cvs-
s1,s2 heard
No murmurs
Resp-BAE +
NVBS heard
Abdomen-
Shape-scaphoid
Tenderness more in right hypochondrium
No palpable masses
Liver and spleen not palpable.
Lateral view- 
Cns-nfnd

Fever charting-

Investigations-
24/9/21-

Haemogram-
Hb-11.9
Tlc-19,000
Plt-3.55
Rft-
Blood urea-14
Serum na-141
Sr.k+ 4.5
Sr.cl- 54
Sr.creat- 1.0 
Serology-hbs ag,hiv,hcv-negative



Ecg-
Ultrasound abdomen-
Haemogram-25/9/21-

On 26/9/21-



Haemogram-27/9/21

Haemogram on 28/9/21-

Review ultrasound was done-




Provisional diagnosis-Liver abscess(single abscess in segment 7 of right lobe of liver)
Plan of care-
1.plenty of oral fluids
2.inj.metrogyl 750 mg IV tid
3.tab.pan 40 mg po od
4.inj.optineuron 1 amp IV od
5.inj.tramadol 1 amp in 100 ml NS IV sos
6.tab.ultracet 1/2 tab /po/qid
7.tab.pcm 650 mg /po/sos
8.inj.piptaz 4.5 mg/IV/tid
9.bp,pr monitoring 6th hourly.

On day-4,inj.piptaz 4.5 mg IV tid was removed and inj.magnx forte 1.5 mg IV bd was added.

Day 1 SOAP notes-
S- pain abdomen more in right upper quadrant,one fever spike.
O-bp-110/70
Pr-78
Rr-16
Cvs-s1,s2 heard
Resp-BAE +
Per abdomen-soft,tenderness in right hypochondrium
Cns-nfnd
Provisional diagnosis-Liver abscess(single abscess in segment 7 of right lobe of liver)
Plan of care-
1.plenty of oral fluids
2.inj.metrogyl 750 mg IV tid
3.tab.pan 40 mg po od
4.inj.optineuron 1 amp IV od
5.inj.tramadol 1 amp in 100 ml NS IV sos
6.tab.ultracet 1/2 tab /po/qid
7.tab.pcm 650 mg /po/sos
8.inj.piptaz 2.5 gm IV bd
9.bp,pr monitoring 6th hourly.


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