Final Practical Short Case

 This is an online E log book 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 series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"


CHIEF COMPLAINT:-

35 year old male came to our hospital on 1/02/2022 with chief complaints of upper abdomen pain since one week,fever since one week ,backpain since 4 days.



HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 20 days back ,then he observed yellowish discolouration of eyes and got admitted to near by hospital.

later 1week back he developed pain abdomen which was insidious in onset, gradually progressive. 

Pain in right hypochondrium and gastric region which is aggrevated on sleeping during night and relieved during standing.

4 days back he developed back pain ,which is dull aching type.

Fever is on and off since one week, high grade not associated with chills, rigor, cold, cough, body pains.

No history of nausea , vomiting,loose stools.

No history of bleeding manifestations.

No history of renal stones


PAST HISTORY:-

Not a k/c/o DM,HTN,asthma , epilepsy,TB .

Had a hernia operation 8 years back .


PERSONAL HISTORY:-

Diet - mixed

Appetite - decreased since 1 week

Sleep- adequate

Bowel movements- dark stools 

Bladder -yellow urine with burning sensation

Addictions- alcohol,360 ml, regular, since 10 years

Smoking -20 cigarettes per day since 10years

GENERAL PHYSICAL EXAMINATION:-

Patient is conscious, coherent, cooperative,well oriented with time , place and person. 

No sign of clubbing, cyanosis

Icterus- present 

Bipedal edema present.

No generalized lymphadenopathy.


Vitals-

Temp- afebrile 

Bp-110/70 mm hg

Pr- 86 bpm

Rr-20 cpm

Spo2- 98% on RA




Systemic examination

RS- bae+

Cvs-S1 S2 +,No murmurs heard

P/A - tenderness + at right hypochondrium and epigastric region

Cns- no abnormality detected.















Investigations
3/2/22
HB-10.2
TLC- 17,900
PLT- 5.1

Serum amylase- 60 
Serum lipase- 28

RFT
Serum urea- 37
Serum creatinine- 1.1
Sodium- 130
Potassium- 6
Chloride- 98

3/2/22
LFT
TB- 4.40
DB- 3.12
AST/ALT- 96/145
ALP- 586
TP- 5.3
Alb- 2.6
A/G- 0.94

PT -17 sec
APTT- 34 sec
INR- 1.25 


Diagnosis:-
Liver abscess secondary to ? Amoebic or pyogenic 

Plan of treatment 
1. INJ. METROGYL 750MG/IV/TID
2. INJ. MAGNEX FORTE 1.5MG/IV/BD
3. INJ. PAN 40MG/IV/BD
4. INJ.  THIAMINE1 AMP IN 100ML NS/IV/ OD OVER 30 MIN
5. INJ. TRAMADOL 1 AMP IN 100ML NS/IV/OVER 30MIN/ SOS
6. INJ. DICLOFENAC 3ML=75MG IM/BD
7. TAB. PCM 650 MG PO/QID
8. INJ. NEOMOL 1G IV/SOS







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