38 yrs old male with complaints of chest pain and fever since 10 days

 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.  

Cheif complaints:- 

38 year old male , resident of miryalaguda,mobile technician by occupation came to OPD with cheif complaints of chest pain since 10 days and intermittent fever since ten days

History of presenting illness:- 

Patient was apparently alright 10 days ago he went to Maharashtra, he felt cold and chills there and smoked two packs of cigarettes.later that night he had complains of right hypochondriac pain relieved automatically after a while. From next day he had complains of fever low-grade

Intermittent not associated with chills and Rigor went to local RmP Doctor who prescribed inj PIPTAZ 4.5gmBD for 6days

Symptoms subsided.

Fever on and off since then

Since yesterday patient has fever High-grade intermittent associated with chills and Rigor Evening Rise of temperature present.

Complains of Right side chest pain aggreviated on taking deep breaths

Radiated to Right Hypochondriac region

 No C/o loss of appetite

No c/o loose stool; vomitings or constipation

History of 2-3 episodes of loose stool 10days ago




Daily routine:- patient is Mobile technician by occupation,he wakes up daily at around 8am and completes his daily routine, eats breakfast  and goes to his shop by 10 am around 2 he eats lunch mostly from outside hotels and closes his shop by 9:30 and spends time with his friends and drinks 90 ml of alcohol almost 4 times a week and will have dinner,sleeps at  around 11 pm .

He smokes daily about 12-15 cigarette since he is 20 years old .

He drinks wisky regularly that is 4-5 times a week since he is 20 years old. 

Past history:- not a known case of diabetes mellitus, hypertension, tuberculosis, asthma, epilepsy

Family history:- not significant

Personal history:- 

Diet- mixed 

Appetite - normal 

Bowel and bladder - regular 

Addictions:- drinks 90ml alcohol daily since he is 20 years old, and smokes 12-15 cigerettes per day since he is 20 years old


General examination:- 


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


Moderately built, moderately nourished


Pallor:- present 


Icterus:- absent 


Cyanosis:- absent 


Clubbing:- absent


Generalized lymphadenopathy:- absent


Bilateral pedal edema :- absent 


Vitals:- 


Bp:110/60 mmhg 


Pulse rate:-90 bpm 


RR:- 19 cycles per min


Temp :-102.3 °F


GRBS:- 80 mg/dl 


Systemic examination:-


Cvs :- s1,s2 heard no murmurs


Cns :- no focal neurological deficits 


Abdomen :- soft ,non tender 


Rs:- BAE present 


Investigations:- 






















 

Provisional diagnosis:- 


Liver abscess (Rt.lobe segment 6&7)? Amoebic liver abscess with liquifaction(30%) with dimorphic Anemia 2° to B12 deficiency? Gi losses ( dysentery) 


Treatment:- 


INJ. METROGYL 500MG IV TID


INJ.PAN 400MG IV OD 7AM


INJ.THIAMINE 100MG in 100ML NS IV BD


INJ.NEOMOL 1gm IV SOS( if temperature 101)


TAB.DOLO 650 MG PO TID

...



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