42year old male patient with abdominal pain ,shortness of breath and cough with sputum.

42year old male patient with abdominal pain ,shortness of breath and cough with sputum.


Date of admission: 11/1/23
January 18, 2023
This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs.

A 42 year old male patient, farmer by occupation, resident of Nalgonda, came to our hospital with the cheif complaints of-
Fever since 3 days, Abdominal pain since 3 days, Shortness of breath since 2 days and Cough with sputum since 2 days.

History of present illness:-
Patient was apparently assymptomatic 3 days ago and then he noticed fever which was sudden in onset, gradually progressive, high grade, associated with chills, rise of temperature during nights and subside by early morning.
Pain in the hypochondrium and epigastric region since 3 days which was sudden in onset, gradually progressive, non-radiating and dull-aching type of pain. No aggravating and relieving factors. Pain wasn't relieved by medication.
Shortness of breath(Grade 2) since 2 days and cough with expectorant since 2 days mucoid in consistency and also associated with chest pain.
Loss of appetite since 3 days
No history of loose stools, vomitings, weight loss.
No history of outside food intake

History of past illness:-
No history of similar complaints in the past.
Not a known case of diabetes, hypertension, tb, epilepsy, asthma.

Personal history:-
 mixed diet.
Appetite:-Decreased
Sleep:-Adequate
Bladder and bowel movements:-Regular
Chronic alcoholic(90ml) since 5 yrs and chronic smoking since 20 years(1 packet).

Drug and allergic history:-
No known relevant drug and allergic history

Family history:-
No significant family history.

General examination:-
Patient is conscious, coherent, cooperative and well oriented to time, place and person.
No Pallor
No Icterus
No Clubbing
No Cyanosis
No Lymphadenopathy
No Edema of feet
No Malnutrition
Mild dehydration

Vitals:-
Temperature-98.6 F
Pulse rate-104 bpm
RR-30 cpm
BP-110/70 mm/hg



SYSTEMIC EXAMINATION:-

RESPIRATORY SYSTEM-
Lower Respiratory Tract:
Inspection-
Chest is asymmetrical
Shape-Crescentic
Trachea-Midline
No drooping of shoulders
No supra clavicular/infra clavicular hollowing
Widening of ribs
No sinuses
No scars
No dilated veins
Asymmetric chest expansion
Abdomino-thoracic movement with respiration
Palpation-
Chest-Asymmetrical chest movements i.e., asymmetric expansion
Measurements-
Inspiration-30 cms
Expiration-29.5 cms
Difference-0.5 cms
Hemithorax-15 cms
Trachea-Midline
Intercoastal widening
Tactile fremitus-Decreased
Vocal fremitus-Decreased
Percussion-
Non-tender
Dullness on percussion-4th intercoastal space
Ascultation-
Breath sounds absent
Added sound-Rub
Vocal resonance-Decrease

Abdomen examination-
Inspection-
Shape of the abdomen-Scaphoid
Flanks-full
No abdominal distention visible
Umbilicus-Position-Midline
                  Shape-Inverted
No scars
No sinuses
No scratch marks
No puncture marks
No dilated veins
No visible peristalsis
Palpation-
Liver-not palpable
Spleen-Non palpable
Percussion-
No fluid thrill.         
No shifting dullness heard
Ascultation-
Bowel sounds heard 4/min



Oral examination:
Hyperpigmented gingiva
Plaque present
Calculus present 
Tongue normal
No gingival enlargement
No halitosis
No Oral thrush
Provisional diagnosis:
Liver abscess with Pleural effusion

Investigations:
Temperature chart:
Heamogram
CUE
BLOOD UREA
SERUM ELECTROLYTES 
SERUM CREATININE 
Urine protein/creatinine ratio:
 
Random blood sugar
Fasting blood sugar
Post lunch blood sugar
HbA1c
Blood parasites 
LFT
Chest X-ray
USG chest
USG abdomen
ECG
Colour doppler 2D echo



Treatment:-
IV Fluids NS RL @ 100 ml/hr
Inj. Monocef 2gm/IV/BD
Inj. Metrogyl 750mg/IV/TID
Inj. Pantop 40mg/IV/TID
Inj. Optineuron lamp 100ml NS/IV/OD
Inj. Thiamine 200mg in 100ml NS/IV/BD
Tab. Dolo 650mg PO/6th hourly
Inj. Neomol 1gm/IV/SOS



























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