Detailed Treatment Process
Male, 72 years old
Outpatient record Chief complaint: Chills and fever for 1 day History of present illness: Chills and fever developed 1 day ago, with a maximum body temperature of 39.9℃. No dizziness. He felt dry mouth, polydipsia and polyuria. No nausea or vomiting, no chest pain, no chest tightness or shortness of breath, no abdominal pain or diarrhea, no urinary frequency, urgency or pain, no redness or pain in the limbs, no limb numbness, and no limitation of limb movement. Body temperature decreased after taking ibuprofen capsules but tended to recur. Past history: Generally healthy (denied history of major cardiovascular and cerebrovascular, pulmonary, hepatic, renal, or endocrine diseases); denied history of infectious diseases such as hepatitis or tuberculosis. Vaccinations up to date. Denied major surgical history. Had a history of liver abscess. Denied history of hypertension, coronary heart disease, or diabetes. No blood transfusion history. Denied history of food or drug allergy. Denied smoking or alcohol use. Allergy history: Denied food or drug allergy history Physical examination: Height: 168 cm, weight: 63 kg, body temperature: 38.1℃, pulse: 109 beats/min, respiration: 20 breaths/min, blood pressure: 134/75 mmHg, BMI: 22.3 kg/m². Conscious, autonomous body position, calm appearance, cooperative with examination. Alert, no jaundice in skin or sclera, bilateral pupils equal and round at 3 mm diameter, sensitive light reflex. Pharynx red, tonsils not enlarged. Coarse breath sounds in both lungs, no obvious dry or wet rales. Heart rhythm regular. Soft abdomen, no obvious tenderness. Clear speech, tongue in midline. Muscle strength grade 5 in all four limbs. 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, hypersensitive C-reactive protein: 153.35 mg/L; February 21 emergency coagulation four items: Prothrombin time: 12.8 seconds, international normalized ratio: 1.12, fibrinogen: 7.686 g/L; February 21 emergency biochemical routine (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; Temporary CT showed: Slightly low-density lesion in the right lobe of the liver, please correlate with clinical findings. Gallbladder wall thickening. Emergency lower abdominal CT plain scan showed no obvious signs of acute emergency.
Laboratory report Specimen type: Whole blood sample Receipt time: January 29 10:40 Collection time: January 29 08:08 Clinical diagnosis: Type 2 diabetes NO\Item\Result Reference interval Unit Test method 1. Glycated hemoglobin 7.50↑ (4.50-6.30%)
Laboratory report Specimen type: Serum Receipt time: January 29 10:01 Collection time: January 29 08:08 Clinical diagnosis: Type 2 diabetes NO\Item Result Reference interval 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. Liver abscess; 2. Diabetes; 3. Hepatic dysfunction Discharge diagnosis: 1. Liver abscess; 2. Diabetes; 3. Hepatic dysfunction; 4. Hypokalemia Hospital stay: 14 days Admission status: The patient was admitted due to “fever for 2 days” Physical examination on admission: Body temperature: 39.1℃, pulse: 122 beats/min, respiration: 20 breaths/min, blood pressure: 121/56 mmHg. Clear consciousness, smooth breathing, no jaundice in skin or sclera. Coarse breath sounds in both lungs, no obvious dry or wet rales heard. No heart murmur. Soft abdomen, no tenderness, no rebound tenderness, no muscle guarding. Liver and spleen not palpable below the costal margin. Murphy sign negative. Mild positive liver percussion tenderness. No abdominal mass. Negative shifting dullness. Bowel sounds 4 times/min. Good limb movement and sensation. No pathological reflexes elicited. February 21 hospital blood routine: WBC 9.4 * 10⁹/L, N 82.6%, CRP 153.35 mg/L; emergency myocardial enzyme spectrum aspartate aminotransferase 52 U/L. CT: Slightly low-density lesion in the right lobe of the liver, please correlate with clinical findings. Gallbladder wall thickening. Emergency lower abdominal CT plain scan showed no obvious signs of acute emergency. Diagnosis and treatment process: 1. Main examination results: February 22 blood routine hypersensitive 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, hypersensitive C-reactive protein: 164.45↑ mg/L; February 22 coagulation function test [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 determination: Glycated hemoglobin A1c: 6.8↑%; February 22 thyroid function test + 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 type identification + irregular antibody: ABO blood type (forward and reverse typing): Type A, Rh(D) blood type: Positive, Rh(E) blood type: Positive, irregular antibody screening test: Negative; February 22 inpatient urine routine: Glucose: 4+↑; 2. Main treatment: After admission, anti-inflammatory and liver-protective symptomatic treatment was given. Discharge status: The patient had no fever, no abdominal pain or distension, no nausea or vomiting. Physical examination: Clear consciousness, smooth breathing, no jaundice in 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 hypersensitive 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, hypersensitive C-reactive protein: 17.05↑ mg/L; March 5 liver function test + electrolyte determination + renal function test [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. Nutrition guidance: Low-fat diet 3. Rehabilitation guidance: Daily activities 4. VTE guidance: Early mobilization, avoid dehydration. 5. Discharge precautions: Suggest re-examination of liver and gallbladder ultrasound, blood routine, and liver function in half a month. 6. Follow-up plan: Return to the general surgery specialist clinic of our hospital in one month. Chief physician every Tuesday morning, associate chief physician every Wednesday morning, associate chief physician every Thursday morning, chief physician every Saturday morning. Seek outpatient follow-up promptly if any discomfort occurs. March 6 10:26
Several months ago, the patient was also hospitalized for liver abscess. The above describes the second occurrence of liver abscess.