A 55 yr old male

"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 patient\"s clinical problems with collective current best evidence based inputs. 

I\"ve 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 clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

 CASE :

 A 55year old male, toddy climber by occupation came with complaints of pain in abdomen and fever.

FOLLOWING IS MY ANALYSIS OF THE PATIENT\"S PROBLEM :

The problems in order of priority I found are :

1) Severe pain abdomen since 10 days

2) Fever since 7 days.

3) Decreased appetite since 7 days.

CHIEF COMPLAINTS: 

                                A 55 year old male patient, toddy climber by occupation, resident of miryalguda, came with complaints of : 

1) Pain abdomen since 10 days.

2) Fever since 7 days.

3) Decreased appetite since 7days.

HISTORY OF PRESENTING ILLNESS: 

Patient was apparently asymptomatic 10 days back and later developed -

1) Severe pain abdomen in the right upper quadrant region of abdomen, which was sudden in onset, gradually progressive, dragging type and non radiating. It is aggravated on standing position and relieved for sometime upon taking medication.

2) He later developed fever since 1 week which was high grade, continuous type and associated with chills and rigor. It is not associated with cold, cough, shortness of breath, neck pain, giddiness, headache and sweating. It is relieved mildly upon taking medications.

-No complaints of chestpain, palpitations and burning micturition.

HISTORY OF PAST ILLNESS: 

        Patient was admitted in the hospital for 3 days with similar complaints 14 days back and was given IV antibiotics for 3 days.

•There is no history of DM /HTN /EPILEPSY/ ASTHMA /CVA /CAD.

TREATMENT HISTORY : 

    •3 day high - dose antibiotics course given 14 days back.

PERSONAL HISTORY:

       •Appetite - Decreased since 1 week

       •Bowel and bladder - Regular

       •Micturition - Normal

       •Addictions - Toddy consumption -1 bottle/day since 30 years

                            -Tobacco in the form of beedi - 10/day

FAMILY HISTORY: 

  •There is no relavent family history

GENERAL PHYSICAL EXAMINATION:

The patient is conscious, coherent and cooperative, sitting comfortably on the bed.

- He is well oriented to time, place and person.

- He is moderately built and moderately nourished.

Vitals:

- Temperature: He is now afebrile

- Pulse: 76 beats per minute, regular, normal in volume and character. There is no radio-radial or radio-femoral delay. The condition of the arterial wall is normal.

- Blood pressure: 110/80 mm of Hg. 

- Respiratory rate = 16 cycles per minute.

- JVP is normal

-Mild icterus is seen on sclera

 

- Pedal Edema is noticed

     - Pitting type.

     - Progressive in nature 

     - Extent up to ankles

- There is no Pallor, Clubbing, Cyanosis, Generalized lymphadenopathy 

-Spo2 -96% on room air 

-RR- 16 cpm

-Cardiovascular System - S1, S2 heard, no murmurs 

-Respiratory System - Decreased air entry and bilateral fine crepitations are present in right lower lobe and left lower lobe.

•Abdomen examination:

1) Shape of the abdomen:Normal

2) Tenderness in the right upper quadrant of abdomen noticed

3) There is no palpable mass

4) Hernial orifices are normal

5) There is no free fluid 

6) Liver not palpable

7) Spleen not palpable

8) Bowel sounds heard

DIFFERENTIAL DIAGNOSIS OF THIS CASE:

Bilateral pedal edema

• Venous insufficiency/thrombophlebitis.
• Drugs: NSAIDS, Steroids.
• CHF.
• Lymphedema.
• Renal failure.
• Liver failure.

PROVISIONAL DIAGNOSIS : Liver Abscess

INVESTIGATIONS:

Complete Blood Picture

Liver Function Tests

Renal Function Tests

Culture & Sensitivity Report:

Chest X ray

USG abdomen

TREATMENT RECIEVED TILL NOW: 

DRUGS GIVEN:

•PERCUTANEOUS DRAINAGE WITH PIGTAIL\"S CATHETER WAS DONE TO DRAIN THE ABSCESS

MY THOUGHTS IN THIS CASE: 

Based on right upper quadrant pain, 14 day fever,pedal edema and mild icterus and investigations, the anatomy of location of the problem confines to Liver. Based on history of the patient, there is underlying liver pathology and bacterial infestation causing liver abcess and it is confirmed by ultrasound .