A 30 year old male with fever and abdominal pain

 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 male driver by occupation came to the opd with chief complaints of fever since 5 days and pain abdomen since 1day.

History of presenting illness:

Patient was apparently asymptomatic 5days back then he developed high grade fever,intermittentand associated with chills and rigor,relived temporarily on taking medication.

Dragging type of pain in right iliac right lumbar and right hypochondriac regions,non radiating.

No h/o vomiting,loose stools,burning micturation,cough and sob.

Past history:

No h/o hypertension,diabetes,epilepsy,tuberculosis,asthma.

Family history:

Not significant 

Personal history:

Diet-mixed

Sleep-adequate 

Appetite-normal

Bowel and bladder movements- regular

Addictions-consumes alcohol occasionally and he also consumes toddy occasionally.

General examination:

Patient is conscious,coherent,cooperative to time,place and person.

Moderately built and moderately nourished

Pallor-absent

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Edema-absent

Vitals:

Temperature-100F

Pulse rate-90bpm

Respiratory rate-17cpm

Blood pressure-130/80mmHg

Spo2-99%

GRBS-185mg%

Systemic examination:

CVS-S1S2 heard

RS-BAE+,NVBS

P/A-tenderness in right hypochondriac,right lumbar and right iliac regions

CNS-NFND

Investigations:

Hemogram:

Hb-13

TLC-13,700

Pl-2.6L

LFT:

TB-0.96

DB-0.19

AST-38

ALT-39

ALP-134

TP-6.6 

ALB-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 

ECG:

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