GENERAL MEDICINE CASE DISCUSSION
66 years old male with fever, loose stools & pain abdomen since 5days
1st June,2023
This is an a 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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.
CASE :-
A 66 years old male who is Maggan worker by occupation ,resident of Nalgonda came to the opd with Cheif complaints of
C/o Fever since 10 days
C/o Loose stools since 5days
C/o Pain abdomen since 5 days
HISTORY OF PRESENTING ILLNESS:-
Patient was apparently asymptomatic 10days back then he developed fever which was insidious in onset , High grade fever, continuous, a/w chills & rigor ,relieved on medication ,
No c/o evening rise of temperature ,weight loss, nausea,vomitings, burning micturition.
He also had C/o loose stools since 5days ,3 episodes per day ,very small volume, watery consistency .
No h/o pus in stools , blood in stools, non foul smelling, worms in stools.
He had C/o Pain abdomen (Epigastric region) since 5days which was insidious in onset, diffuse type , non radiating, no aggravating factors, relieved on passing stools.
PAST HISTORY :-
N/k/c/o HTN,DM , Asthma,TB,Epilepsy,CVA,CAD
No past surgical history.
PERSONAL HISTORY :-
Marital status : married
Diet : mixed
Appetite : normal
Bowel and bladder: regular
Sleep : adequate
Addictions :
A chronic alcohol for 40 years drinks 90 ml per day (regularly)
He is a smoker (3-4 per day) since the age of 7years.
GENERAL EXAMINATION:-
Patient was concious coherent cooperative well built and nourished , well oriented to time place and person at the time of presentation.
Pallor : absent
Icterus : absent
Cyanosis : absent
Clubbing : present
Lymphadenopathy : absent
Edema : absent
Vitals
Temperature : 99.2F
PR : 76 bpm
BP : 120 / 80 mm Hg
RR : 14 cpm
Spo2: 98 on RA
SYSTEMIC EXAMINATION:-
I) Per Abdomen :
INSPECTION :-
Shape of abdomen -Flat
Umbilicus - inverted
No scars, sinuses, straie
No visible pulsations & visible peristalsis
PALPATION :-
All inspectory findings are confirmed
No local rise of temperature
Tenderness present in the epigastric region
No palpable mass present
No palpable lymphadenopathy
No organomegaly
Hernial orificies - Free
PERCUSSION :-
No signs of fluid thrill & shifting dullness
Resonant note heard (except liver dullness)
AUSCULTATION :-
Bowel sounds present
No bruit heard
CNS:-
HIGHER MENTAL FUNCTIONS:
Oriented to time place and person
Immediate memory:Intact
Short term memory:Intact
Longterm memory:Intact
No delusions and hallucinations.
Motor system
Power:-
Rt UL - 5/5 Lt UL-5/5
Rt LL - 5/5 Lt LL-5/5
Tone:-
Rt UL - normal
Lt LL- normal
Rt LL- normal
Lt LL- normal
Reflexes:
Right Left
Biceps: ++ ++
Triceps: ++ ++
Supinator: ++ ++
Knee: ++ ++
Ankle: + + ++
Plantar: flexor. Flexor
CVS:-
S1S2 heard,no murmurs.
Respiratory system examination
Bilateral air entry present.
Normal vesicular breath sounds present.
INVESTIGATIONS:-
Hemogram
1/6/23
3/6/23
CUE
4/6/23
Blood Urea
Serum creatinine
Serum Electrolytes
LFT
RBS
HIV
HBsAg
Anti HCV
Chest x-ray
USG Abdomen
2D ECHO
Blood culture &sensitivity
Provisional Diagnosis:-
AMEOBIC LIVER ABSCESS
TREATMENT:-
1/6/23
1. INJ. PIPTAZ 4.5gm IV/TID
2. INJ. METRONIDAZOLE 500mg IV/TID
3. INJ. THIAMINE 200mg in 100ml NS IV/BD
4. INJ.OPTINEURON 1amp in 100mlNS IV/OD
5.INJ. PANTOP 40mg IV/OD
6.INJ.NEOMOL 1gm IV/SOS
7.TAB.PCM 650mg po/sos
8. BP/PR/RR/TEMP CHARTING 4TH HOURLY
2/6/23
1. INJ. PIPTAZ 4.5gm IV/TID
2. INJ. METRONIDAZOLE 500mg IV/TID
3. INJ. THIAMINE 200mg in 100ml NS IV/BD
4. INJ.OPTINEURON 1amp in 100mlNS IV/OD
5.INJ. PANTOP 40mg IV/OD
6.INJ.NEOMOL 1gm IV/SOS
7.TAB.PCM 650mg po/sos
8. BP/PR/RR/TEMP CHARTING 4TH HOURLY
3/6/23
1. INJ. PIPTAZ 4.5gm IV/TID
2. INJ. METRONIDAZOLE 500mg IV/TID
3. INJ. THIAMINE 200mg in 100ml NS IV/BD
4. INJ.OPTINEURON 1amp in 100mlNS IV/OD
5.INJ. PANTOP 40mg IV/OD
6.INJ.NEOMOL 1gm IV/SOS
7. BP/PR/RR/TEMP CHARTING 4TH HOURLY
4/6/23
1. INJ. PIPTAZ 4.5gm IV/TID
2. INJ. METRONIDAZOLE 500mg IV/TID
3. INJ. THIAMINE 200mg in 100ml NS IV/BD
4. INJ.OPTINEURON 1amp in 100mlNS IV/OD
5.INJ. PANTOP 40mg IV/OD
6.INJ.NEOMOL 1gm IV/SOS
7. BP/PR/RR/TEMP CHARTING 4TH HOURLY
Comments
Post a Comment