Chapter IV

This chapter presents the chief complaint, history of present illness, history of past

illness, and the admitting diagnoses of our client upon admission at the Sarangani Bay

Specialists Medical Center.

Cheif Complaints The patient presents with multiple complaints, including chest pain

radiating to the back, persistent fever for the past two weeks, abdominal

pain, intermittent headaches, loss of appetite, pallor, and positive

tachypnea.

History of present The patient's current illness began two weeks ago prior to the admission,
illness
he experienced fatigue and malaise, followed by worsening right upper

quadrant abdominal pain, low-grade fever, chills, and weakness. Over

the past few days, there was a decline in appetite and unintentional

weight loss. The symptoms escalated to chest pain, back pain, and

headaches. On evaluation, positive tachypnea and pallor were observed.

History of past In 2013, the patient was diagnosed of pulmonary tuberculosis (PTB),
illness
which was attributed to excessive tobacco use. The diagnosis prompted

lifestyle changes, including the cessation of tobacco use, reflecting a

proactive approach to health following the initial tubercolosis episode.

Family Health The patient has a family history of hypertension and diabetes.
History

Admitting T/C Pulmonary Tubercolosis relapse, anemia of chronic disease

Diagnosis
 The patient verbalized multiple concerns during the interview and health assessment

such as chest pain radiating to the back, persistent fever for the past two weeks, abdominal

pain, intermittent headaches, loss of appetite, pallor, and positive tachypnea is being

observed. According to the patient his current illness began two weeks ago prior to the

admission, he experienced weakness in his body and pain in right upper quadrant. He also

experienced low-grade fever and chills. And, over the past few days, there was a decline in

appetite and unintentional weight loss to the patient health status. The patient final diagnosis

was sepsis secondary to pyogenic liver abscess at right. The ultrasound report that the patient

liver is slightly enlarged and lobular hypoechoic lesion with low level internal echoes is noted

in the right lobe at segment. This particular findings may have a potential connection to the

patient chief complaints before his hospital admission.

In the year 2013, the patient stated that he was hospitalized and diagnosed with

pulmonary tuberculosis and undergone a six months medication prior to the prescription of

his doctor. However, in the present time, the admitting diagnosis of the patient was

pulmonary tubercolosis relapse. During a medical examination, a thorough X-ray analysis

was conducted on his chest, uncovering a series of concerning health issues. The X-ray

images distinctly showed the presence of pneumonia with pleural effusion at right. The other

findings showed that there are interstitial infiltrates in both hilar area. Pulmonary vascular

markings are within normal. Trachea is in midline, heart is not enlarged, the right

costophrenic sulcus is blunted and bony thorax is unremarkable. It is important to note that

minor blunting may be caused by scarring or chronic atelectasis. Effusions first become

apparent on lateral upright radiographs with blunting of the posterior costophrenic angle.

Lastly, the patient has a family history of hypertension and diabetes. This familial

background may contribute to the patient's overall health profile and warrants ongoing

monitoring for potential risk factors and preventive measures.

 According to a study, a liver abscess is defined as a pus-filled mass in the liver that

can develop from injury to the liver or an intraabdominal infection disseminated from the

portal circulation. The majority of these abscesses are categorized into pyogenic or amoebic,

although a minority is caused by parasites and fungi. Most amoebic infections are caused by

Entamoeba histolytica. The pyogenic abscesses are usually polymicrobial, but some

organisms are seen more commonly in them, such as E.coli, Klebsiella, Streptococcus,

Staphylococcus, and anaerobes. While the incidence is low, it is essential to understand the

severity of these abscesses because of the high mortality risk in untreated patients. The usual

pattern of abscess formation is that there is leakage from the bowel in the abdomen that

travels to the liver through the portal vein. Many cases have an infected biliary tract that

causes an abscess via direct contact. Liver abscesses can be classified in a variety of ways:

One is by location in the liver. 50% of solitary liver abscesses occur in the right lobe of the

liver (a more significant part with more blood supply), less commonly in the left liver lobe or

caudate lobe. Another method is by considering the source: If the cause is infectious, the

majority of liver abscesses can be classified into bacterial (including amebic) and parasitic

sources including hydatiform cyst (Akhondi & Sabih, 2019).

Additionally, this disease may occur secondary to an umbilical vein catheterization or

infection in other parts of the body, and is associated with immune deficiencies, especially

chronic granulomatous disease. There are no specific signs and symptoms, but an

unexplained fever with upper abdominal tenderness and an enlarged liver were present in all

of our cases. A liver-spleen scan is the most useful diagnostic test, demonstrating a filling

defect in the liver. A single abscess may be unroofed and drained. When multiple abscesses

are found, as many as possible are drained, but long-term specific antibiotic therapy is the

most important treatment (Ogden & Rives, 2014).

 Chapter V

Health Assessment

This chapter outlines the results of the functional assessment and the health status of

our patient by the results of the conducted health assessment of the digestive, respiratory,

cardiovascular, integumentary, musculoskeletal, and neurologic systems.

Assessment 11/07/2023

Inspection ● Abdomen appears symmetrical

● No visible masses, distension or bulges

● Skin is intact

● Free from lesions, rashes or discoloration

Auscultation ● Bowel sound is present and normal.

● Soft gurgling or tinkling sound at a rate of about 5-

30sounds per minute

● No absence of bowel sounds

Percussion ● Percussion was omitted due to the recent surgery to avoid

potential discomfort or complications at the surgical site.

Palpation ● Palpation was omitted due to the recent surgery to avoid

potential discomfort or complications at the surgical site.

 During the examination, the patient's digestive system shows no immediate

indications of any abnormalities or problems. In general, these results fall within the

predicted normal range. For a comprehensive assessment, it is crucial to take consideration of

the patient's medical history, symptoms, and any other pertinent circumstances. However, the

main concern of the patient was he was suffering from constipation after his surgery. This

negative change in his bowel habits is indicative of a unhealthier digestive system that will

cause further complications in his body.

Constipation in adults refers to infrequent bowel movements or difficulty passing

stool. It's a common condition characterized by the presence of hard, dry stools and may be

accompanied by discomfort or straining during bowel movements. Causes include a lack of

fiber in the diet, inadequate fluid intake, sedentary lifestyle, certain medications, or

underlying medical conditions. Lifestyle modifications, dietary changes, and increased water

intake are often recommended for managing constipation. Persistent or severe cases may

require medical evaluation to identify and address underlying issues (Sabath, 2018).

Furthermore, constipation following surgery is a common issue attributed to factors

like anesthesia, pain medications (especially opioids), reduced mobility, dehydration, and

dietary changes. Anesthesia and certain medications can temporarily slow bowel movements,

while immobility and dehydration further contribute to this postoperative concern.

Encouraging early mobility, maintaining hydration, incorporating fiber-rich foods, and, if

needed, adjusting medications can help manage postoperative constipation effectively. If

constipation persists or becomes severe, consulting a healthcare provider is advisable for

personalized guidance and intervention (Habath, 2014).

 Respiratory System

Assessment/Vital Signs 11/07/2023

Inspection ● Symmetrical chest expansion is normal during breathing.

● No visible deformities or abnormalities in the chest wall.

● Respirations are within normal range.

Palpation ● Palpation was omitted due to the recent surgery to avoid

potential discomfort or complications at the surgical site.

Percussion ● Percussion was omitted due to the recent surgery to

avoid potential discomfort or complications at the

surgical site.

Auscultation ● Presence of crackles upon auscultation

During the respiratory assessment of the patient with a history and admitting

diagnosis of Pulmonary Tuberculosis relapse, several observations were made. His vital

signs, including the temperature, heart rate, and respiratory rate, were within normal limits. In

adddition, upon auscultation crackles sound was being heard which indicate issue like

pulmonary edema or pneumonia. And, also his chest x-ray impression has showed that the

patient have pneumonia pleural effusion at right and there was interstitial infiltrates in both

hilar are. Furthermore, appropriate measures should be taken to assess and manage the

respiratory infection or inflammation, especially initiating appropriate antibiotic therapy.

Close monitoring of the patient's respiratory status and vital signs is crucial to ensure timely

intervention and optimal respiratory function.

 Pneumonia in adults is a respiratory infection characterized by inflammation of the

lung tissue. It can be caused by various infectious agents, including bacteria, viruses, and

fungi. Common symptoms include cough, shortness of breath, chest pain, fever, and fatigue.

Diagnosis typically involves a physical examination, chest X-rays, and sometimes laboratory

tests. Treatment often includes antibiotics for bacterial pneumonia, antiviral medications for

viral cases, and supportive care such as rest, hydration, and pain management. It's essential to

seek prompt medical attention if pneumonia is suspected, especially in adults with underlying

health conditions or weakened immune systems (Sayad, 2019).

The recurrence of tuberculosis (TB), commonly referred to as relapse, can be

attributed to several factors. One primary cause is incomplete treatment, where individuals

fail to complete the entire course of prescribed anti-TB medications. This incomplete

treatment may lead to the survival of bacteria and the development of drug-resistant strains.

Additionally, conditions that weaken the immune system, such as HIV infection or certain

medications, increase the susceptibility to TB relapse. Close contact with active TB cases,

malnutrition, and excessive alcohol or substance abuse are also recognized contributors.

Moreover, individuals may be at risk if they fail to receive adequate follow-up care and

monitoring after completing initial TB treatment. Prevention of TB relapse involves

addressing these factors through complete and proper treatment, managing underlying health

conditions, and adopting a healthy lifestyle. Regular medical follow-ups and strict adherence

to prescribed medications play pivotal roles in averting the recurrence of TB (Fahard, 2016).
Reference:

Ogden, W. W., Hunter, P. R., & Rives, J. D. (2014). Liver abscess. Postgraduate

Medicine, 30(1), 11-19.

Akhondi H, Sabih DE. Liver Abscess. In: StatPearls. StatPearls Publishing, Treasure
Island (FL); 2022. PMID: 30855818.