A 32 yr male came with the complaints of Fever since 7 days

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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. 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

A 32 yr old male came with the complaints of fever since 1 week 

HOPI 

Patient was apparently asymptomatic 1 week back and then developed fever which was sudden in onset gradually progressive high grade associated with chills and generalised weakness for which he went to local RMP and took medication for 2 days still the symptoms didnot subside and further investigation like blood test done and his blood sugars were 300mg/dl 

As the symptoms didnot subside they went to Miryalagudam hospital there USG was done and impression showed HEPATIC ABSCESS 

and refered to our hospital 

Patient came to hospital yesterday and USG was done impression showing: 

NO H/o vomitings 

No h/o cough cold diarrhoea 

Past history: 

K/c/o DM type 2 since 2 months and was on metformin hydrochloride

N/kc/o HTN TB Epilepsy BA 

 Personal history: 

Diet mixed 

Appetite normal 

Sleep Adequate

Bowel decreased since 3 days and passed stools yesterday 

Bladder movements are regular 

Addictions: occasional alcohol consumption since 5 years but stopped consumption from 2 months 

Occasionally smoker since 5 years 

General examination

Pat is c/c/c well oriented to time place person 

He is moderately built and nourished

No signs of pallor icterus cyanosis clubbing lymphadenopathy generalized edema 

Vitals 

Temperature - 102 F 

BP - 110/70 mm hg 

PR - 86 BPM 

RR - 16 cpm 

Systemic examination

CVS - S1 S2 Heard no murmurs 

RS - BAE + NVBS 

CNS : NFND 

PER ABDOMEN EXAMINATION:

Inspection:

Shape of the abdomen:Distended 

Flanks:Free 

Umbilicus:center,oval shape 

Skin-normal,no sinuses,scars,striae 

No dilated viens 

Abdominal wall moves with respiration 

No hernial orifices 

Palpation:

No local rise of temperature,no tenderness.All inspectory findings are confirmed by palpation. 

Liver:Not palpable,Non tender,no hepatomegaly

Spleen:Not palpable,non tender,no splenomegaly 

Kidney:Non tender and not palpable 

No other palpable swellings 

Percussion: 

On abdomen percussion tympanic note is heard

Liver span:12cms in mid clavicular line 

Spleen:No dullness is heard 

PROVISIONAL DIAGNOSIS:  

HEPATIC ABSCESS 

K/C/O DM TYPE 2 

INVESTIGATIONS: 

USG DONE on 7/10/23 

Impression: Hepatic abscess of size 9x7 noted in 5 and 6 segments of liver with 20% liquefaction

TREATMENT: 

Inj.NEOMOL 1G IV STAT 

Inj.MAGNEX FORTE 1.5GMS IV STAT 

Inj.METROGYL 500MG IV TID 

Inj.PAN 40MG IV/OD 

IV FLUIDS - NS RL 

Tab.DOLO 650MG PO/SOS 

TEPID SPONGING