38 year old male with liver abscess

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.  

HISTORY OF PRESENT ILLNESS:

He was apparently asymptomatic 12 days back and then he developed fever which is sudden in onset gradually progressive continuous type associated with chills and rigor; no aggravating and relieving factors; not associated with diurnal variation and evening rise of temperature. H/o abdominal pain since 12 days which is sudden in onset gradually progressive non radiating and diffuse type aggravated by taking deep breaths and relieved on taking rest.

No h/o of nausea, vomiting, loose stools, loss of appetite, weight loss, burning micturition, decrease in urination, swelling of legs

No h/o of shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, platypnea

No h/o of cough and cold.

No h/o blurring of vision, dizziness, limb weaknesses, facial weakness.

PAST HISTORY:

No h/o similar complaints in the past 

No h/o diabetes, hypertension, asthma, TB, CAD, thyroid abnormalities.

PERSONAL HISTORY:

Diet-mixed

Appetite- normal

sleep- regular

bowel and bladder movements- normal

H/o alcohol intake for every 2-3 days 90ml for 20 yrs

H/o smoking 10 ciggeretes per day for 20 yrs

No h/o any drug and food allergies

FAMILY HISTORY:

No relevant family history

DIAGNOSIS BASED ON HISTORY:

Liver abscess 

Biliary tract obstruction

cholelithiasis

cholodocholelithiasis

cholodochal cyst

GENERAL EXAMINATION:

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

moderately built and nourished. 

no pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema

Vitals:

temp: afebrile

pr; 90bpm

rr: 16bpm

bp: 130/80 mm hg

SYSTEMIC EXAMINATION:

Based on symptoms presented 

ABDOMEN EXAMINATION:

Inspection:

shape: flat 

umbilicus: central and inverted

flanks are free

hernial orifices are intact

no scars and sinuses and engorged veins 

no visible pulsations and visible mass

Palpation:

Superficial palpation:

no local rise of temperature

tenderness present in right hypochondrium

no guarding and rigidity

Deep palpation:

Liver:

palpable with mild tenderness in the right hypochondrium does not move with respiration

soft in consistency surfaces are sharp with regular margins and upper border is not palpable so the liver is enlarged.

Spleen: not palpable

kidney: not palpable

no other swellings palpable

Percussion:

no fluid thrill, shifting dullness, puddle sign.

Liver span: liver dullness starts in rt 4th intercostal space upto rt subcostal margin with span of 12cm in the midclavicular line

Auscultation:

bowel sounds heard 10 per minute in lt and rt side of the umbilicus

auscultopercussion test is negative

no bruit and venous humm heard 

CARDIOVASCULAR EXAMINATION:

S1 and S2 heard.

no murmurs and added sounds heard 

RESPIRATORY EXAMINATION:

Normal vesicular breath sounds in all lung fields

NERVOUS SYSTEM EXAMINTION:

No focal neurological deficits

PROVISIONAL DIAGNOSIS:

LIVER ABCESS

INVESTIGAATIONS:

ON CHEST XARY : RT SIDED PLEURAL EFFUSION

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