Final exam long case

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A 35 year old male patient came to the casuality with chief complaint of upper  abdominal pain since one week.

History of present illness : 

Patient was apparently asymptomatic 20 days back then he noticed yellowish discoloration of eyes , abdominal pain since one week in the right hypochondrium and gastric region which is insidious in onset and gradually progressive ,  back pain since 4 days.

No history of  nausea ,vomiting . 

No history of loose stools , constipation. 

Past history : 

No history of hypertension. 

No history of diabetic mellitus. 

No history of , CAD , asthma, Tuberculosis , Epilepsy.

Personal history : 

Diet - mixed 

Appetite - decreased

Sleep - adequate 

Bowel movements - normal 

Bladder - yellow urine with burning sensation .

Addictions - alcoholic ,360 ml per day since 10 years

                Smoking  - 20 cigarettes per day since 10 years

                      

Family history : 

No members of the family have similar complaints. 

General examination : 

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

Pallor - absent

Icterus - present

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy - absent 

Edema - bipedal edema present 

              

VITALS : 

Temperature - Afebrile 

Pulse rate -  86 beats / min 

Respiratory rate - 20/ min 

Blood pressure - 130/80 mmHg 

SYSTEMIC examination : 

Cardiovascular system : 

No thrills 

S1 S2 heard 

No cardiac murmurs 

Respiratory system : 

No dyspnoea  

No wheeze 

Breath sounds - vesicular 

Position of trachea - central 

Abdomen : 

Shape of abdomen - distended 

Tenderness  - present 

Central nervous system : 

Level of consciousness - conscious 

Speech - normal 

Investigations : 

                Investigations

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

LFT

TB- 4.40

DB- 3.12

AST/ALT- 96/145

ALP- 586

TP- 5.3

Alb- 2.6

A/G- 0.94

Provisional Diagnosis : 

Liver abscess secondary to amoebic or pyogenic

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