Final exam long case

 "This is online E log book to discuss our patients de- identified health data shared after taking his or her guardian's signed informed consent hear we discuss our individual patients problems through a series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This E log book also reflex my patient centered online learning portfolio and your valuable inputs on comment box is welcome."

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




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