38 year old male with liver abscess
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.
HISTORY OF PRESENT ILLNESS:
He was apparently asymptomatic 12 days back and then he developed fever which is sudden in onset gradually progressive continuous type associated with chills and rigor; no aggravating and relieving factors; not associated with diurnal variation and evening rise of temperature. H/o abdominal pain since 12 days which is sudden in onset gradually progressive non radiating and diffuse type aggravated by taking deep breaths and relieved on taking rest.
No h/o of nausea, vomiting, loose stools, loss of appetite, weight loss, burning micturition, decrease in urination, swelling of legs
No h/o of shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, platypnea
No h/o of cough and cold.
No h/o blurring of vision, dizziness, limb weaknesses, facial weakness.
PAST HISTORY:
No h/o similar complaints in the past
No h/o diabetes, hypertension, asthma, TB, CAD, thyroid abnormalities.
PERSONAL HISTORY:
Diet-mixed
Appetite- normal
sleep- regular
bowel and bladder movements- normal
H/o alcohol intake for every 2-3 days 90ml for 20 yrs
H/o smoking 10 ciggeretes per day for 20 yrs
No h/o any drug and food allergies
FAMILY HISTORY:
No relevant family history
DIAGNOSIS BASED ON HISTORY:
Liver abscess
Biliary tract obstruction
cholelithiasis
cholodocholelithiasis
cholodochal cyst
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative and well oriented to time, place and person.
moderately built and nourished.
no pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema
Vitals:
temp: afebrile
pr; 90bpm
rr: 16bpm
bp: 130/80 mm hg
SYSTEMIC EXAMINATION:
Based on symptoms presented
ABDOMEN EXAMINATION:
Inspection:
shape: flat
umbilicus: central and inverted
flanks are free
hernial orifices are intact
no scars and sinuses and engorged veins
no visible pulsations and visible mass
Palpation:
Superficial palpation:
no local rise of temperature
tenderness present in right hypochondrium
no guarding and rigidity
Deep palpation:
Liver:
palpable with mild tenderness in the right hypochondrium does not move with respiration
soft in consistency surfaces are sharp with regular margins and upper border is not palpable so the liver is enlarged.
Spleen: not palpable
kidney: not palpable
no other swellings palpable
Percussion:
no fluid thrill, shifting dullness, puddle sign.
Liver span: liver dullness starts in rt 4th intercostal space upto rt subcostal margin with span of 12cm in the midclavicular line
Auscultation:
bowel sounds heard 10 per minute in lt and rt side of the umbilicus
auscultopercussion test is negative
no bruit and venous humm heard
CARDIOVASCULAR EXAMINATION:
S1 and S2 heard.
no murmurs and added sounds heard
RESPIRATORY EXAMINATION:
Normal vesicular breath sounds in all lung fields
NERVOUS SYSTEM EXAMINTION:
No focal neurological deficits
PROVISIONAL DIAGNOSIS:
LIVER ABCESS
INVESTIGAATIONS:
ON CHEST XARY : RT SIDED PLEURAL EFFUSION
Treatment:-
INJ. METROGYL 500MG IV TID
INJ.PAN 400MG IV OD 7AM
INJ.THIAMINE 100MG in 100ML NS IV BD
INJ.NEOMOL 1gm IV SOS( if temperature 101)
TAB.DOLO 650 MG PO TID
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