A 30 YEAR OLD MAN WITH PAIN IN THE ABDOMEN ALONG WITH FEVER

 THIS IS AN 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

A 30years old man driver by occupation came to the opd with chief complaints of fever since 6 days and pain abdomen since 3 days.

History of presenting illness:

Patient was apparently asymptomatic 6 days back then he developed High grade, intermittent fever along with  chills and rigor which relieved temporararily medication.

2 days back he had dragging type of abdominal pain in right iliac ,right lumbar and right hypochondriac regions ,it was non radiating in nature 

No h/o vomiting,loose stools,burning micturation,cough and shortness of breath.

PAST HISTORY:

NO H/O DM, HTN,CAD,Asthma,TB,Epilepsy

PERSONAL HISTORY:

DIET:Mixed

APPETITE:normal

BOWEL AND BLADDER movements:  regular

SLEEP:adequate

ADDICTIONS: consumes toddy regularly and alcohol occasionally.

FAMILY HISTORY:

No significant family history

GENERAL EXAMINATION:

Patient is conscious,coherent,cooperative well oriented to time,place and person

He is moderately built and nourished

NO signs of pallor ,icterus,clubbing,cyanosis,lymphadenopathy,edema

VITALS at the time of admission:

TEMPERATURE:100°F

RR:17 cpm

PR:90 bpm

BP:130/80 mm Hg

SPO2:99 %

GRBS:185 mg %

SYSTEMIC EXAMINATION:

CVS: S1 and S2 are heard ,no murmurs

RESPIRATORY SYSTEM: BAE Present ,NVBS 

P/A: Tenderness in right ilac and hypochondriac regions

CNS: NO focal neurological deficits .

INVESTIGATIONS:

HEMOGRAM:

Hb-13

TLC-13,700

Pl-2.6L

LFT:

Total Bilirubin-0.96

Direct Bilirubin-0.19

AST-38

ALT-39

ALP-134

TP-6.6 

ALBUMIN-4.21

A/G-1.76

RFT:

Urea:-17

Creatinine:-1.0

Ca++-:9.6

Po4-:3.5

Na+:138

K+:4.5

Cl-:99

CUE:

ALB-nil

Pus cells:-2-3

Amylase-42.1

Lipase-21.4

RBS-116gm/dl 

USG:

E/o 2.5x2.6cm heteroechoic lesion noted in left lobe of liver.

Liver abscess(with poor liquefaction-30%)

E/O 8-9mm hyperechoic focus noted in gall bladder— s/o gallbladder polyps.

E/O few freely mobile hyperechoic foci 1-2mm with posterior acoustic shadow noted in gall bladder— gallbladder microliths.

Provisional diagnosis:

Liver abscess with choleliathasis.

Treatment:

Inj.MONOCEF 1gm Iv bd

Inj.METROGYL 100ml Iv TID

IVF 20 NS@ 500ml/hr

Inj.PAN 40 iv OD

Inj. OPTINEURONN 1amp+100ml NS

Tab.DOLO 650mg PO sos

Inj.NEOMOL 1gm iv sos