Medicine Case Discussion

 

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

 the topic of "patient clinical analysis data " to develop my competency in reading and comprehending clinical data including clinical history,clinical findings, investigations and come up with a diagnosis and treatment plan

LIVER ABSCESS 

A 55 year old male patient who is a palm tree climber by Occupation 

came on 17th April 2021 with the chief Complaints of  

PAIN ABDOMEN SINCE ONE WEEK 

DECREASE APPETITE SINCE ONE WEEK

 FEVER SINCE 2 DAYS

HISTORY OF

PRESENTING ILLNESS

Patient was apparently asymptomatic 1 week back, then he developed pain abdomen in Right Upper Quadrant dragging type, non radiating, sudden onset, non progressive not associated with nausea / vomiting / loose stools  

Fever since 2days which was high grade associated with chills and rigors not associated with cold , cough, SOB, Headache, neck pain, dizziness and sweating 

No history of chest pain, palpitations,Burning micturition. 

PAST HISTORY

Not a known Case of Diabetes, Hypertension, Tuberculosis, Epilepsy, CVDs

PERSONAL HISTORY

Diet - Mixed 

Appetite - Decreased 

Bowel and Bladder - Regular

 Sleep - Adequate 

Addictions - Chronic Alcoholic since 30 years.  ( 1 bottle of Toddy per day),  Consumes alcohol Occasionally

Beedis 10 per day since 30 years

FAMILY HISTORY

Not Significant

GENERAL EXAMINATION

Patient was Conscious, Coherent and Cooperative. 

Well oriented to time, place ,person 

Moderately built and moderately nourished

vitals

Temperature - 100 F 

pulse - 76 bpm 

Blood pressure - 90/ 70 mm Hg 

Respiratory rate - 14 cycles per min  

pallor - present

No signs of icterus, clubbing, lymphadenopathy, Edema

SYSTEMIC EXAMINATION 

Abdominal Examination

Soft , Tender

Decreased movements in Right Upper Quadrant on respiration

No hernial orifices

Respiratory Examination 

B/L reduced breath sounds on IAA (Rt more than left)

CVS Examination

S1 and S2 Heard

 No murmurs

Liver abscess Aspirate

INVESTIGATIONS

 During hospital stay

TREATMENT

Oral fluids - 2L 

Injection pantop - 40 mg/IV/OD

Injection Ampicillin - 2G/IV/TID

 Injection Clindamycin - 600mg / IV/TID

 Tab Ultracet po/ sos 

syrup Aristozyme 15ml po/TID

 Protein powder 2 tbsp in one class of milk 

Neb with budecort 12th hourly 

Ascoryl 10ml po/TID

He was admitted in hospital for 10days and taken antibiotics treatment 

when gastro opinion was taken pigtail catheterisation adviced ,but was not done as the abscess was not drainable

He was discharged on 26 April 2021 and from then he is on weekly follow up 

Patient was discharged on 26 April 2021 with discharge medications and He was adviced for weekly follow up

Oral fluids 

Protein powder 2tbsp in 1 glass of milk

 Tab septran ds - ( 800mg/160mg) po/OD   for 14 days 

Tab Clindamycin - 600mg po/TID for 7 days 

Tab Pantop 40mg PO/OD for 14 days

 syrup Aristozyme - 10ml PO/TID for 7 days

 Syrup Ascoryl - 10ml PO/TID for 5 days

 Tablet zincovit - PO/OD for 15 days

 

Follow up on 3rd May 2021

    Patient subjectively feeling better

     No Complaints 

     O/E  - pt was C/C/C  

     Temperature - Afebrile

     Pulse - 78bpm

     Blood pressure - 110/70 mmHg 

• CVS Examination - S1 ,S2 Heard, No murmurs
• Respiratory Examination - BAE (bilateral air entry) + , NVBS
• Abdominal Examination - Soft and Non   tender 
• CNS Examination - NFND

Follow up on 12th May 2021

Patient subjectively feeling better

     No Complaints 

     O/E  - pt was C/C/C  

     Temperature - Afebrile

     Pulse - 76bpm

     Blood pressure - 100/70 mmHg

• CVS Examination - S1 ,S2 Heard, No murmurs
• Respiratory Examination - BAE +, NVBS
• Abdominal Examination - Soft and Non   tender 
• CNS Examination - NFND

   Follow up on 19th May 2021

Patient subjectively feeling better

     No Complaints 

     O/E  - pt was C/C/C  

     Temperature - Afebrile

     Pulse - 74bpm

     Blood pressure - 110/70 mm

• CVS Examination - S1 ,S2 Heard, No murmurs
• Respiratory Examination - BAE +, NVBS
• Abdominal Examination - Soft and Non   tender 
• CNS Examination - NFND

Treatment 

Tablet Metrogyl - 400mg PO/TID 

Tablet pantop 40mg PO/OD 

Tablet Ultracet 1/2 PO/QID 

Injection Tremadol 1 amp in 100ml slow IV/SOS 

plenty of oral fluids 

USG guided Aspiration was done  and pus sent for Culture and Sensitivity