52 y/o high grade fever and chills

52 YR MALE WICH HIGH GRADE FEVER AND CHILLS

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


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.


Chief comp

A 52 yr male bricklayer by occupation with chief comp of highgrade fever since 1 week (which subsided 2 days back) and  associated with chills


Hopi

Pt was apparently asymptomatic 15 days back then he developed high grade fever for one week  associated with chills and rigor, continues, no diurinal variation, and burning micturition. Not associated with pain abdomen, loose stools, nausea, vomiting, cough, cold. For which he took consultant at choutuppal and was diagnosed to have 50 % of liver pus. He came to opd on 3rd Oct and was on medication(inj ceftriaxone and inj metronidazole)for one week and got admitted  on 11th oct

Past history 

Not kco DM, HTN, ASTHMA, CAO,TB, EPILEPSY 



TREATMENT HISTORY 



PERSONAL HISTORY 

Diet mixed 

Appetite normal 

Sleep adequate 

Bowel and bladder movt Regular, burning micturition 

Addictions - he consumes toddy 2 bottles daily evening, no h/o tobacco smoking or chewing 

General examination 

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

Moderately built and nourished 

Comfortable sitting 


No signs  of pallor, icterus, cyanosis, clubbing, generalized lymphadenopathy, oedema 













Vitals

Bp 124/90 mmhg

PR  112 bpm

Temp afebrile

RR 16 cpm


Systemic examination 


Abdomen 









Inspection

umbilicus is central in position 

Skin normal,no scars or engorged veins are present 


Palpation 

No local raise in Temperature 

Non tender

Moves with respiration

No hepatomegaly

No splenomegaly 


Percussion 

Liver span 12cm along mid clavicular line

Auscultation 

Bowel sounds heard


CVS 

S1S2 heard,no murmurs


RS 


Cns


Investigations 

Stools for microscopy, hemogram, left,rft,chest x-ray,fcg
















Provisional diagnosis 

Liver abscess 2° ?amoebic or 2° ?pyogenic 



Treatment 

11/10/22

Inj PAN 40MG IV OD

INJ METROGYL 750MG IV TID

INJ MONOCEF 1GM IV BD

INJ TRAMADOL 1AMP IN 100ML NS IV SOS

INJ ZOFER 4MG IV SOS


12/10/22

O/E

PR 88bpm

Bp 120/90

Cvs s1 s2 heard no murmurs

Resp bae+, nvbs heard

P/a soft non tender

Non distended

Liverspan 12 cm

Cns nfnd




 INJ METROGYL 750MG IV TID

INJ MONOCEF 1GM IV BD

INJ TRAMADOL 1AMP IN 100ML NS IV SOS

INJ ZOFER 4MG IV SOS


13/10/22




14/10/22

PR 88bpm

Bp 120/80 mmhg

Cvs s1s2 +

Rs bae +

P/a soft nt

Liver span 14 cm

Grbs 150


INJ METROGYL 750MG IV TID

INJ TRAMADOL 1AMP IN 100ML NS IV SOS

INJ ZOFER 4MG IV SOS

Comments

Post a Comment

Popular posts from this blog

My Journey as an Intern In Medicine

Image
I am Sanjana Thota, Intern posted in the General Medicine Department from 1/12/23 until 31/1/24. “To cure sometimes, to relieve often, to comfort always.”- Edward Livingston Trudeau.  1) Self Reflection on my Medical Career: My first case taken in the manner if an e-log during my 2nd year Medicine Posting. https://sanjanathotarollno141.blogspot.com/2022/09/a-70-yr-old-female-with-involuntary.html?m=1 Through this process, I learned how to document the process of history taking, diagnosis, investigations and the treatment of a patient. During my internship, I came across cases such as DKA, Heart Failure, CKD, SLE, Septic Shock,CVA, Epilepsy and common chronic diseases such as Diabetes, Hypothyroidism and Hypertension. I witnessed an episode of GTCS and the acute management of such a case in the ICU. I also learned how to diagnose and further evaluate a case of MI / ACS.I learned about spinal cord lesions, how to perform a full CNS examination and how to localize a stroke. My journey in
Read more

60 y/o male with hypertension, heart failure and decreased urine output.

Image
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 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. Patient was apparently asymptomatic 3 months ago, then he developed b/l pedal edema, initially extending only up to the ankles, which gradually progressed up to both the thighs, over the last 15 days. Patient c
Read more

A 70 yr old female with involuntary movements in upper and lower limb

Image
MEDICINE E LOG BOOK This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 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. CHIEF COMPLAINT Altered sensorium since 12:00 am midnight, involuntary movement in upper and lower limb since 12:00 am, loss of speech after 12:00 am HISTORY OF PRESENTING ILLNESS Pt was app
Read more