52 yr male wich high grade fever and chills

- October 13, 2022

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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 diagnosis and treatment plan.

Chief comp

A 52 yr male bricklayer by occupation with chief comp of highgrade fever since 1 week (which subsided 2 days back) and associated with chills

Hopi

Pt was apparently asymptomatic 15 days back then he developed high grade fever for one week associated with chills and rigor, continues, no diurinal variation, and burning micturition. Not associated with pain abdomen, loose stools, nausea, vomiting, cough, cold. For which he took consultant at choutuppal and was diagnosed to have 50 % of liver pus. He came to opd on 3rd Oct and was on medication(inj ceftriaxone and inj metronidazole)for one week and got admitted on 11th oct

Past history

Not kco DM, HTN, ASTHMA, CAO,TB, EPILEPSY

TREATMENT HISTORY

PERSONAL HISTORY

Diet mixed

Appetite normal

Sleep adequate

Bowel and bladder movt Regular, burning micturition

Addictions - he consumes toddy 2 bottles daily evening, no h/o tobacco smoking or chewing

General examination

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

Moderately built and nourished