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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 a diagnosis and treatment plan.
60 year old female came to casualty with chief complaints of fever since 6 days, decreased appetite snice 6 days, pain abdomen since 3 days.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 6 days back then she developed fever which is high grade associated with chills,not associated with cold,cough,burning micturition.
Appetite decreased not associated with nausea,vomitings,loose stools,constipation, weight loss.
Pain abdomen which is diffuse,pricking type ,radiating,aggravated on right lateral position and relieved on sitting.
Pt went to miryalaguda care hospital I/V/O fever,decreased appetite on 17/6/21.usg abdomen showed mild hepatomegaly with multiple abcess
HISTORY OF PAST ILLNESS
Not k/c/o HTN,diabetes, asthma,tuberculosis,epilepsy
PERSONAL HISTORY
Married
Occupation:labourer
Appetite:normal
Diet:mixed
Bowel and bladder:regular
No known allergies
Alcohol history
-intake of whisky twice a week
-180ml
FAMILY HISTORY
Not significant
PHYSICAL EXAMINATION
No pallor,icterus,cyanosis,clubbing,lymphadenopathy, oedema
Temperature:101F
PR:108bpm
BP:100/70mmhg
RR:24cpm
Spo2:95%
GRBS:100mg/dl
SYSTEMIC EXAMINATION
Abdominal examination
Inspection
Shape -scaphoid
Umblicus-inverted
Equal movements in all quadrants
No visible pulsation,dilated veins,localized swellings
Palpation
Local rise of temperature in right hypochondrium
Tenderness in epigastrium and right hypochondrium
Guarding and rigidity in epigastrium and right hypochindrium
Mild enlargement of liver
Percussion
Uppet border of liver is
Liver span
Fluid thrill and shifting dullness absent
Ascultation
Ascultatory findings are normal
CVS :No thrills,no murmurs,s1 and s2 heard
RESPIRATORY SYSTEM
bilateral air entry present,NVBS,no crepts
CNS -NAD
PROVISIONAL DIAGNOSIS:
Multiple liver abcess
INVESTIGATIONS
TREATMENT
Day 1
Iv fluids -NS,RL,DNS @75ml/hr
INJ METROGYL 750mg IV/TID
INJ PANTOP 40mg IV OD
INJ ZOFER 4mg IV/SOS
INJ TRAMADOL 1 AMP in 100ml NS slow IV /OD
INJ OPTINEURON 1 AMP in 100ml NS IV/OD
Tab PCM 650mg PO/TID
Bp/pulse rate/temp 4th hourly
GRBS 6th hourly
Day 2
Iv fluids -NS,RL,DNS @75ml/hr
INJ METROGYL 750mg IV/TID
INJ PANTOP 40mg IV OD
INJ ZOFER 4mg IV/SOS
INJ TRAMADOL 1 AMP in 100ml NS slow IV /OD
INJ OPTINEURON 1 AMP in 100ml NS IV/OD
INJ MONOCEF 1gm IV/BD
INJ AMIKACIN 250mg IV/BD
Tab PCM 650mg PO/TID
Bp/pulse rate/temp 4th hourly
GRBS 6th hourly
Day 3
INJ METROGYL 750mg IV/TID
INJ PANTOP 40mg IV OD
INJ ZOFER 4mg IV/SOS
INJ TRAMADOL 1 AMP in 100ml NS slow IV /OD
INJ OPTINEURON 1 AMP in 100ml NS IV/OD
INJ MONOCEF 1gm IV/BD
INJ AMIKACIN 250mg IV/BD
Tab PCM 650mg PO/TID
Tab LIMCEF PO/OD
Bp/pulse rate/temp 4th hourly
GRBS 12th hourly
Day 4
INJ METROGYL 750mg IV/TID
INJ PANTOP 40mg IV OD
INJ ZOFER 4mg IV/SOS
INJ TRAMADOL 1 AMP in 100ml NS slow IV /OD
INJ OPTINEURON 1 AMP in 100ml NS IV/OD
INJ MONOCEF 1gm IV/BD
INJ AMIKACIN 250mg IV/BD
Tab PCM 650mg PO/TID
Tab LIMCEF PO/OD
Bp/pulse rate/temp 4th hourly
GRBS 12th hourly
Day 5
INJ METROGYL 750mg IV/TID
INJ PANTOP 40mg IV OD
INJ ZOFER 4mg IV/SOS
INJ NEOMOL 100ml /IV/SOS IF temp >101°F
INJ OPTINEURON 1 AMP in 100ml NS IV/OD
INJ MONOCEF 1gm IV/BD
INJ AMIKACIN 250mg IV/BD
Tab PCM 650mg PO/TID
Tab LIMCEF PO/OD
Bp/pulse rate/temp 4th hourly
GRBS 12th hourly
DISCHARGE SUMMARY
Discharge date -29/6/21
TREATING FACULTY
DR.RAKESH BISWAS[HOD]
DR.A.VAISHNAVI[PGY2]
DR.M.VINAY[PGY1]
DR.M.MANSA[PGY1]
DR.SAI VITTAL[INTERN]
DR.ROOPA[INTERN]
DR.SHIVANI[INTERN]
DR.PREETHI[INTERN]
DR.DEEKSHITHA[INTERN]
DR.RISHIK[INTERN]
DIAGNOSIS
-MULTIPLE LIVER ABCESS
CHIEF COMPLAINTS
60 year old female came to casualty with chief complaints of fever since 6 days, decreased appetite snice 6 days, pain abdomen since 3 days.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 6 days back then she developed fever which is high grade associated with chills,not associated with cold,cough,burning micturition.
Appetite decreased not associated with nausea,vomitings,loose stools,constipation, weight loss.
Pain abdomen which is diffuse,pricking type ,radiating,aggravated on right lateral position and relieved on sitting.
Pt went to miryalaguda care hospital I/V/O fever,decreased appetite on 17/6/21.usg abdomen showed mild hepatomegaly with multiple abcess
Please upload her current fever chart into her E log
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