Detailed Treatment Process
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Male, 72 years old
Outpatient record Chief complaint: Chills and fever for 1 day History of present illness: The patient developed chills and fever 1 day earlier, with a maximum temperature of 39.9°C. He reported no dizziness, but noted dry mouth, increased thirst, and increased urination. There was no nausea, vomiting, chest pain, chest tightness, shortness of breath, abdominal pain, diarrhea, urinary frequency, urgency, or pain. No redness, swelling, or pain in the limbs, no numbness, and no limitation of limb movement. He took ibuprofen capsules, which temporarily reduced the fever, but it recurred easily. Past history: Generally healthy (denied significant history of cardiovascular, cerebrovascular, pulmonary, hepatic, renal, or endocrine diseases); denied history of hepatitis, tuberculosis, or other infectious diseases. Vaccinations up to date. Denied major surgical history. Had a history of hepatic abscess. Denied hypertension, coronary heart disease, or diabetes. No blood transfusion history. Denied food or drug allergies. Denied smoking or alcohol use. Allergy history: Denied food or drug allergies Physical examination: Height 168 cm, weight 63 kg, temperature 38.1°C, pulse 109 beats/min, respiration 20 breaths/min, blood pressure 134/75 mmHg, BMI 22.3 kg/m². Alert and oriented, comfortable posture, cooperative with examination. Clear consciousness, no jaundice of skin or sclera, pupils equal and round at 3 mm, brisk light reflex. Red pharynx, tonsils not enlarged. Coarse breath sounds in both lungs, no obvious dry or wet rales. Regular heart rhythm. Soft abdomen, no obvious tenderness. Clear speech, tongue midline. Limb muscle strength grade 5. Auxiliary examinations: February 21 emergency blood routine + CRP: Lymphocyte percentage 8.5%, neutrophil percentage 82.6%, eosinophil percentage 0.2%, lymphocyte count 0.8 × 10⁹/L, monocyte count 0.81 × 10⁹/L, neutrophil count 7.7 × 10⁹/L, high-sensitivity C-reactive protein 153.35 mg/L; February 21 emergency coagulation panel: Prothrombin time 12.8 seconds, international normalized ratio 1.12, fibrinogen 7.686 g/L; February 21 emergency biochemistry (7 items): Aspartate aminotransferase 52 U/L, glucose 10.9 mmol/L, potassium 3.29 mmol/L, sodium 134 mmol/L, chloride 98 mmol/L, creatine kinase 32 U/L; Emergency CT showed a slightly low-density lesion in the right lobe of the liver; clinical correlation recommended. Gallbladder wall thickening. Emergency plain CT of the lower abdomen showed no obvious signs of acute emergency.
Laboratory report Specimen type: Whole blood sample Received: January 29, 10:40 Collected: January 29, 08:08 Clinical diagnosis: Type 2 diabetes NO Project Result Reference range Unit 1. Glycated hemoglobin 7.50↑ (4.50-6.30%)
Laboratory report Specimen type: Serum Received: January 29, 10:01 Collected: January 29, 08:08 Clinical diagnosis: Type 2 diabetes NO Project Result Reference range Unit 1. Glucose 8.54↑ (3.90-6.10 mmol/L)
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Discharge record Gender: Male Department: Hepatobiliary and Pancreatic Surgery, Minimally Invasive Surgery Admission date: February 21 Discharge date: March 6 Admission diagnosis: 1. Hepatic abscess; 2. Diabetes; 3. Hepatic dysfunction Discharge diagnosis: 1. Hepatic abscess; 2. Diabetes; 3. Hepatic dysfunction; 4. Hypokalemia Hospital stay: 14 days Admission status: Admitted for “fever for 2 days” On admission: Temperature 39.1°C, pulse 122 beats/min, respiration 20 breaths/min, blood pressure 121/56 mmHg. Clear consciousness, normal breathing, no jaundice of skin or sclera. Coarse breath sounds in both lungs, no obvious dry or wet rales. No heart murmurs. Soft abdomen, no tenderness, no rebound tenderness, no muscle guarding. Liver and spleen not palpable below costal margin. Murphy sign negative. Mild positive liver percussion tenderness. No abdominal masses. Negative shifting dullness. Bowel sounds 4 times/min. Normal limb movement and sensation. No pathological reflexes elicited. February 21 blood routine: WBC 9.4 × 10⁹/L, N 82.6%, CRP 153.35 mg/L; emergency myocardial enzymes showed aspartate aminotransferase 52 U/L. CT: Slightly low-density lesion in the right lobe of the liver, clinical correlation recommended; gallbladder wall thickening. Emergency plain CT of the lower abdomen showed no obvious acute findings. Course of diagnosis and treatment: 1. Main examination results: February 22 blood routine + high-sensitivity C-reactive protein: White blood cell count 3.4↓ × 10⁹/L, neutrophil percentage 92.0↑%, neutrophil count 3.1 × 10⁹/L, hemoglobin 131 g/L, platelet count 155 × 10⁹/L, high-sensitivity C-reactive protein 164.45↑ mg/L; February 22 coagulation profile [six items]: Prothrombin time 13.9↑ seconds, international normalized ratio 1.22↑, fibrinogen 6.740↑ g/L, D-dimer 2940↑ μg/L FEU; February 22 glycated hemoglobin: HbA1c 6.8↑%; February 22 thyroid function + ten tumor markers: Triiodothyronine 0.74↓ nmol/L, thyroxine 54.53↓ nmol/L; February 22 procalcitonin + interleukin-6: Procalcitonin 2.36↑ ng/ml, interleukin-6 3255.1↑ pg/mL; February 22 full biochemistry: Total bilirubin 14.0 μmol/L, direct bilirubin 6.5 μmol/L, albumin 34.8↓ g/L, alanine aminotransferase 35 U/L, aspartate aminotransferase 60↑ U/L, glucose 14.81↑ mmol/L, potassium 2.97↓ mmol/L; February 22 blood typing + irregular antibodies: ABO blood type (forward and reverse) A, Rh(D) positive, Rh(E) positive, irregular antibody screen negative; February 22 routine urinalysis: Glucose 4+↑; 2. Main treatment: After admission, anti-inflammatory and liver-protective symptomatic treatment was given. Discharge status: No fever, no abdominal pain or distension, no nausea or vomiting. Physical examination: Clear consciousness, normal breathing, no jaundice of skin or sclera, soft abdomen, no tenderness, no rebound tenderness, no muscle guarding, negative shifting dullness, bowel sounds 4 times/min. March 5 procalcitonin + interleukin-6: Procalcitonin 0.08 ng/ml, interleukin-6 <1.5 pg/mL; March 5 blood routine + high-sensitivity C-reactive protein: White blood cell count 5.6 × 10⁹/L, neutrophil percentage 69.3%, neutrophil count 3.9 × 10⁹/L, hemoglobin 135 g/L, platelet count 276 × 10⁹/L, high-sensitivity C-reactive protein 17.05↑ mg/L; March 5 liver function + electrolytes + renal function [BUN, UA, CREA]: Total bilirubin 13.7 μmol/L, direct bilirubin 5.5 μmol/L, albumin 36.4↓ g/L, alanine aminotransferase 34 U/L, aspartate aminotransferase 27 U/L; Treatment outcome: Cured Discharge instructions: 1. Medication guidance: None 2. Nutritional guidance: Low-fat diet 3. Rehabilitation guidance: Daily activities 4. VTE guidance: Early mobilization, avoid dehydration. 5. Discharge precautions: Recommend repeat liver and gallbladder ultrasound, blood routine, and liver function in half a month. 6. Follow-up plan: Return to our hospital general surgery specialist clinic in one month. Chief physician Tuesday mornings, associate chief physician Wednesday mornings, associate chief physician Thursday mornings, chief physician Saturday mornings. Seek outpatient care promptly if any discomfort arises. March 6, 10:26
Several months earlier the patient had also been hospitalized for a hepatic abscess. The above describes the second episode.