92 Sneha Nadipi
3rd Semester
Under the guidance of Dr.Pavan Kalyan(intern).
This is 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 patients clinical problems with collective current best evidence based inputs.
🖌This is an ongoing case. This blog post will be updated regularly.
A 45 year old male is presented with:
🌡CHIEF COMPLAINTS:
📌Fever since 1 week
📌Dyspnea since 1 week
📌Burning micturaton since 1 week
📌Pain abdomen since 1 week
🌡HISTORY OF PRESENT ILLNESS:
📌Patient was apparently asymptomatic 14 years back.
📌 14 years back during his wife's pregnancy on routine investigations she was found to be HIV positive. On getting tested, he turned out to be HIV positive as well.
📌He was started on medications which he takes regularly.
📌 1 year back - he experienced pain abdomen in the right lumbar region radiating to his lower back for almost a month.
📌He went to a local hospital and was diagnosed to have a right renal calculi for which he used medications for a couple of days and was advised to consume plenty of water.
📌Later he never experienced a similar episode.
📌Since 1 week patients has been experiencing high grade fever associated with chills,
📌 Its more during early morning around 5 am and at midnight around 12 am.
📌 He also feels dyspneic whenever he gets these fever spikes.
📌He also has been experiencing burning micturition since a week along with pain abdomen.
📌His says the pain abdomen he is experiencing is similar to the one he experienced one year back, in his right lumbar region radiating to his lower back.
🌡HISTORY OF PAST ILLNESS:
📌Is a k/c/o Renal caliculi
📌Not a k/c/o DM,HTN,CAD,ASTHMA,TB
🌡 TREATMENT HISTORY :
📌 Tab Dexa along with Paracetamol for his fever
📌Inj. Pipatz–4 doses
🌡️PERSONAL HISTORY : .
- Married
- Apettite loss:No
- Micturition : Burning
- No H/O known drug allergies
-Alcohol : Ocassional alcoholic
🌡PHYSICAL EXAMINATION :
A) GENERAL EXAMINATION :
- Pallor- NO
- lcterus-YES
- Cyanosis-No.
- Clubbing of fingers/toes- No
- Lymphadenopathy-No
-Oedema of feet- No
- Malnutrition - No
-Dehydration -NO
- No H/O pallor, cyanosis , lymphadenopathy , clubbing of fingers or toes , dehydration,odema.
- Temperature : Afebrile
- BP : 100/70 mmHg
- PR : 88 BPM
- SPO2 : 99% at room air
-RR-19 cpm
🌡SYSTEMIC EXAMINATION:
B)Per Abdomen:
-On inspection:
-Scaphoid in shape
-Moving equally on respiration
-No scars, dilated veins
Palpation:
-Tenderness + in right lumbar region
-No guarding, rigidity
-No palpable mass
Percussion:
-Tympanic note+
-Auscultation:
-Bowel sounds +
INVESTIGATIONS:
Serological Investigation:
On 25/7/21(outside hospital )
ECG Findings: Regular Sinus Rythm
TLC:15,000
CUE:10-12 pus cells
USG abdomen-Right lower lobe single abscess measuring around 61*59 mm with partial liquefaction.
On 29/7/21 (In hospital)
HBsAg-Rapid: Negative
Anti HCV antibodies:Non-reactive
PROVISIONAL DIAGNOSIS:
1.Liver Abscess in Right lobe of Liver
2. ? UTI
3. HIV positive
Comments
Post a Comment