A 40 yr old male

A 40 yr old male, works in milk dairy, resident of ramanapet came to casualty with 

COMPLAINTS OF 

1.Pain in Rt loin,hypochondrium & iliac region since 4 days

2.Fever since 7 days

3.1 Episode of Vomiting yesterday 

4.Cough present for 20 minutes at night

5.Burning micturation rarely present since 6 mths

HOPI 

- pt was chronic alcoholic since 20 days, stopped 1 wk back due to fever; drinks 250ml/day

- Gutka chewer since 20 yrs

- Smoker since 20 yrs daily 1 pac, stopped 5 yrs ago

- Pt admitted in a local hospital for fever spikes 2 days ago & got diagnosed with typhoid +

1.PAIN: present on Rt hypochondrium

-Sudden in onset,dragging type started at loin region shifted to sides & front region 

2.FEVER:

- Sudden in onset,intermittent type,stepladder pattern associated with chills and rigors and sweating,decreased on medications 

3.VOMITING:

- 1 episode,non bilious, non projectile,food as content 

4.COUGH:

- Productive, lasted for 20 minutes associated with sputum.abdominal pain increased with cough

PAST HISTORY 

- K/N/C/O - DM,HTN,ASTHMA,THYROID,EPILEPSY,CVA,CAD

- COVID + 6mths ago.pt was adviced not to drink alcohol but pt denied & continously took it 

- USG ABDOMEN: Hepatomegaly+G 1 fatty liver & liver abscess (10 to 20 % liquefaction)

PERSONAL HISTORY 

DIET :Mixed

APPETITE:decreased since 4 days

BOWEL & BLADDER MOVEMENTS: reduced since 4 days 

SLEEP: adequate 

ADDICTIONS:Present 

GENERAL EXAMINATION 

 O/E:-

Patient was c/c/c , moderately built, moderately nourished.

No Icterus, pallor,cyanosis, clubbing, lymphadenopathy

Edema

Vitals:-

Temp: 100°F

Bp: 100/70 mm hg

PR: 76BPM

RR: 40cpm 

Spo2: 99%

Cvs:- 

S1 , S2 heard

No  murmurs.

RS:-

 BAE present.

P/A:-

- Tenderness present in Rt hypochondrium,epigastric & lumbar region 

CNS:- 

HMF intact

Temperature charting

Investigations

30/8/21

Ecg

Hemogram-

Hb-12.7

Tlc- 12400

Plt-3.31

RFT

Sr. Urea- 15

Sr creat- 0.9

Uric acid- 2.1

LDH- 236

Na-140

K- 4.2

Cl-97

LFT

Tb-1.52

Db- -0.60

AST-37

ALT-57

ALP-682

TP-5.3

ALB-2.79

A/G-1.11

amylase- 30

lipase- 24

Serology - 

Hbsag - Negative

HCV-Negative

HIV-negative

chest x ray

Usg abdomen

Hemogram- 2/9/21

PROVISIONAL DIAGNOSIS 

Liver abscess;  alcohol and tobacci dependence

Soap notes day 1

SUBJECTIVE :

Pain on inspiration,fever spike +, nausea+ 

OBJECTIVE : patient is C/C/C

Temp : 101 F

BP- 110/70

PR- 80

Central Nervous System- NAD

Cardiovascular system- S1,S2 HEARD 

P/A - Tenderness present in RT hypochondrium & lumbar region

Respiratory System- BAE +

ASSESSMENT 

Liver abscess , alcohol and tobacco dependence

PLAN OF CARE 

1.inj metrogyl- 750 mg IV TID

2. Inj buscopan 2 cciv SOS

3. Tab pcm 500 mg po/ SOS

4. Tab Ultracet 1/2-1/2-1/2-1/2 QID po

5. Tab .pan 40 mg po of bbf

6. Monitoring vitals 4 th hourly

SOAP NOTES day 2

SUBJECTIVE :-

1 fever spike, 1 episode of vomiting

OBJECTIVE : patient is C/C/C

Temp : 101 F

BP- 100/60 mm Hg

PR- 78 bpm

Central Nervous System- NAD

Cardiovascular system- S1,S2 heard 

P/A - Tenderness present in RT hypochondrium & lumbar region

Respiratory System- BAE +

ASSESSMENT 

Liver abscess , alcohol and tobacco dependence

PLAN OF CARE 

1.inj metrogyl- 750 mg IV 

2. Inj buscopan 2 cciv SOS

3. Tab pcm 500 mg po/ SOS

4. Tab Ultracet 1/2-1/2-1/2-1/2 QID po

5. Tab .pan 40 mg po of bbf

6. Monitoring 4 th hourly bbf

SOAP NOTES day 3

SUBJECTIVE-

1 fever spike,pain in the right hypochondrium Aggravating on inspiration

OBJECTIVE : patient is C/C/C

Temp : 101 F

BP- 110/70 mm Hg

PR- 78 bpm

Central Nervous System- NAD

Cardiovascular system- S1,S2 heard 

P/A - Tenderness present in RT hypochondrium 

Respiratory System- BAE +

ASSESSMENT 

Liver abscess , alcohol and tobacco dependence

PLAN OF CARE 

Inj Metrogyl- 500 mg IV TID

Inj CIPROFLOXACIN 500 mg iv OD

Tab PCM 650 mg PO/ SOS

Tab ULTRACET 1/2-1/2-1/2-1/2 QID po

Tab PAN 40 mg po of bbf

Syp. LACTULOSE 15 ML PO HS

Monitoring 4 th hourly bbf

Temperature charting day 3

SOAP NOTES day 4

SUBJECTIVE-

Mild pain in the right hypochondrium Aggravating on inspiration

OBJECTIVE : patient is C/C/C

Temp : 99 F

BP- 110/70 mm Hg

PR- 82 bpm

Central Nervous System- NAD

Cardiovascular system- S1,S2 heard 

P/A - Tenderness present in RT hypochondrium 

Respiratory System- BAE +

ASSESSMENT 

Liver abscess , alcohol and tobacco dependence

PLAN OF CARE 

Inj Metrogyl- 500 mg IV TID

Inj CIPROFLOXACIN 500 mg iv OD

Tab PCM 650 mg PO/ SOS

Tab ULTRACET 1/2-1/2-1/2-1/2 QID po

Tab PAN 40 mg po of bbf

Syp. LACTULOSE 15 ML PO HS

Monitoring 4 th hourly bbf

Temperature charting day 4