A 40 year old male with fever and pain abdomen

MEDICINE CASE DISCUSSION

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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.