55 yrs old male with c/o pain in abd

 NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.  

PATIENT HISTORY: Pt is a 55 yr old male, doing business supplying small machine parts.

At the age of 12 yrs, he c/o anorexia, incomplete evacuation of stool, and acidity. He was taken to a local Dr. who detected hepatomegaly and prescribed medications, taking which resolved his symptoms within a few days.

At the age of 13, he c/o of high fever (103-104F), headache, and general body weakness lasting for 3-4 days, resolved with medications. 2 yrs later again it happened again.

In 2020, one day he went to an occasion, where in he ate a lot of fries, chicken, and sweets. After returning home at night, he started c/o localized intense pain in rt upper quadrant. The pain was increasing as the night progressed and taking medication for gas did not help. The next day his pain became unbearable and got admitted to a hospital, wherein he was injected with medication to relieve the pain. His pain reduced slowly. USG was gone which detected gallstone. 

He went to a Dr. who did a laparoscopic cholecystectomy. He had no complaints after that.

In 2022, he c/o localized mild pain in upp. rt quadrant. Initially, the pain would occur at any time of the day 1-2 times daily, lasting for 10-15 mins. Then mostly after dinner when he went to sleep in a supine position.  On tossing and turning to either side slowly the pain would disappear after 10-15 mins. For the past few wks, the pain happens 4-5 times a wk. Dr. prescribed paracetamol which reduced pain temporarily. Then USG and CT abd were done which revealed a liver abscess. Dr. performed USG-guided percutaneous drainage, but during a follow-up, Dr. told there had been not much improvement and he would need a laparoscopic drainage of liver abscess. He didn't do any further consultation.

Pt reported for the past few months he is passing brown colored greasy stools.

For the past 15-20 days, he is experiencing incomplete evacuation of stool.

After being diagnosed with a liver abscess he lost 4-5 kgs of wt which he regained gain in the past few months.

Pt denied any history of HTN or DM. 

ADDICTION: He started eating paan with tobacco in it at age of 17 yrs. Used to have 10-15 times daily. After being diagnosed with a liver abscess he eats 1-3 times daily.

CHIEF COMPLAINT AND PT REQ: 1) Pain in the rt quadrant of abd for the past 10 months.

2) c/o incomplete evacuation of bowel for the past 20 days

FAMILY HISTORY: 

Father  -  c/o loose motion, sudden urge to defecate, BPH

Mom - death due to stage 4 gallbladder Ca.





Before USG-guided aspiration, he used to c/o a burning sensation in the smaller circle area.

REPORTS: 











PROVISIONAL DIAGNOSIS: Liver abscess






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