International Chart round

1. International Chart round June 26, 2006

2. Identifying data A 7-year-old boy from Sranburi District, Chainat The history was obtained from his mother and father. Admission date at June 19, 2006

3. Chief complaint He was referred to QSNICH for further investigation of prolonged fever and abdominal pain.

4. Present illness Seven days before admission, he developed a sudden abdominal pain in right para-umbilical area at about 6 hours after dinner. The pain was characterized as dull, without radiation. The pain was relieved by lying still and bending forward. He had no vomiting, diarrhea, or constipation.

5. Present illness He was taken to Sranburi hospital.The physician suspected that his problem was due to overeating and antacid drug was prescribed.The patient reported some clinical improvement during that night. The next morning he developed fever and The same pattern abdominal pain which partially relieved by oral acetaminophen.

6. Present illness At night, however, he had another episode of a high-grade fever with chill and vomiting. He was then taken to Sanburi Hospital. The severity of his symptoms render the attending physician suspected that he might have acute appendicitis. The patient was then hospitalized, CBC was performed, and intravenous fluid and soft diet was given without any clinical improvement.

7. Present illness The patient�s father reported of giving him one dose of MOM before he later developed watery diarrhea. After being hospitalized for 2 days without any signs of improvement, he was asked to be transferred to a private hospital in the metropolitan area.

8. Present illness From the referral letter, the initial examination revealed body temperature of 40 �C, toxic and ill-appearing with no jaundice. The abdomen was tender at epigastrium and right upper quadrant, liver was 2 cm. below RCM and liver span was 10 cm.The complete blood count yielded: hematocrit 37%, white blood cell 14,400, Neutrophil 88%, lymphocyte 10%, monocyte 2%, platelets 157,000.

9. Present illness The urine analysis and stool examination were normal. Although he was treated with intravenous antibiotic and fluid, his fever and abdominal pain did not subside.

10. On the following day (June 15, 2006) an ultrasonogram of the abdomain was taken. The results show normal echotexture of hepatic parenchyma without space-taking lesion, normal gall bladder, pancrease, CBD, spleen and both kidney. There was no ascitis. Present illness

11. One day PTA (June 18,2006), the fever and right upper quadrant abdominal pain were unremitting. A follow-up ultrasonogram was performed revealing three hypoechoic to anechoic oval lesion in segment T6 (near hepatic angle). The right peritoneal space was thickening with hyperdensity. No dilated bile duct. Suggestive of liver abscess. Present illness

12. Present illness No additional treatment was prescribed. The parent then decided to take the child to the Children Hospital.

13. Past history The past history is rather uneventful. He is the third child of the family and was born at Phuket hospital with birth weigh of 3200 gm.

14. Family history Mother, aged 35 years, a farmer, is currently healthy. Father, aged 39 years, a farmer, is currently healthy. (Non smoker) His brothers are eleven years and nine years of age, respectively. Both of them are healthy.

15. Nutrition He was breast-fed until 2 month of age, followed by three meals and 1 to 4 boxes of UHT milk each day. He does not like to consume vegetable.

16. Immunizaion Was completed according to the EPI protocol.

17. Growth & Development WNL. He is now in the second year of a primary school.

18. Environment He lives in a 2-storied suburban house, surrounding with garden and pond.

19. Physical examination General appearance: A slightly overweight boy, good consciousness, coorperative, in moderate discomfort, ill-appearing. BW kgs. Ht cm. Vital signs: BT 40 �c PR 123/min RR 30/min BP 112/63 mmHg

20. Physical examination HEENT: Not pale conjunctiva, anicteric sclera. Dry lip and tongue. Pharynx and tonsil are not injected. Lymph node was not palpable. Heart: Normal heart sounds. No murmur Lung: Normal breath sounds. No crepitation or wheezing.

21. Physical examination Abdomen: Mildly distend, Active bowel sound, soft. Tender at right upper and paraumbilical area. Liver : 2 cm below RCM, span 10 cm, tender on palpation Spleen was impalpable CVA : tender at Rt. side

22. Physical examination Extremities: Normal Neuro examination : Good consciousness, Motor: Grade V Pupils 3 mm. RTL BE.DTR 2+ Babinski�s reflex: no response. Clonus: negative both. No stiffness of neck.

23. Problem lists 1. High grade fever for 7 days. 2. Right upper and paraumbilical abdominal pain 3. Tenderness at right CVA 4. Hepatomegaly

24. Differential Diagnosis 1. Liver abscess 2. Appendicitis 3. Other : Acute cholecystitis UTI Hepatitis

25. Investigations CBC : Hct 35 % Hb 11.8 g% WBC 24,000 N 80% LY 13% Mono 4% Platelet 448,000 UA : Sp.gr.1.010 pH 7 No cell

26. Investigations Electrolyte : Na 137 mEq K 4.86 mEq Cl 101 mEq CO2 24.7 mEq BUN 10.43 mg/dl Cr 0.32 mg/dl Coaggulogram: PT 12.4 INR 1.02 PTT 20.6

27. Investigations LFT : Total protein 6.35 g/dl Alb 2.62 g/dl Glo 3.75 g/dl Chol 170 mg/dl Bilirubin total 0.27 mg/dl direct 0.06 indirect 0.21 AST 17 U/L ALT 16 U/L Alk. Phosphatase 154 U/L