CASE

 Final short case 


This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan 


A 35 year old male patient presented to the opd with chief complaints of pain in the upper abdomen since one week and fever since one week 


HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic one week back and then developed pain in the upper epigastric region and right upper hypochondria region which is insidious in onset and progressively growing in nature 

There is a bit relief of pain on standing position and a little aggravation on sleeping

Fever which is present is one and off and there are no presence of chills , rigors, cough ,nausea , vomitings 

There are no bleeding manifestations seen 


PAST HISTORY: 

patient is not a known case of asthma , hypertension  , epilepsy,  diabetes


PERSONAL HISTORY: 

Diet  - mixed 

Appetite - decreased since one week

Sleep - adequate 

Bowel movements - black stools

Bladder - burning micturition 

Addictions - regular alcoholic since 10 years

Smoking since 10 years


GENERAL EXAMINATION: 


Patient is conscious,  coherent , cooperative and well oriented to time and place 

No signs of clubbing , cyanosis 

Icterus - seen 

Pedal edema - seen


VITALS : 

Temp : afebrile

BP: 110 / 70

Pulse rate : 86 bpm

Respiratory rate  : 20 cpm

Spo2 - 98% on RA


SYSTEMIC EXAMINATION : 

RS - bae + , nvbs 

CVS - S1,S2 +

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


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

Comments

Post a Comment

Popular posts from this blog

2nd internal examination

Image
 1. Anatomical and etiologic localisation for hemiparesis and further management. 2. Etiology and pathogenesis clinical features management complication of acute pancreatitis?  3. Dengue fever clinical features and complications 5. Cushing syndrome 6. Cardiogenic pulmonary edema 7. Rhematoid arthritis 9. Heart failure 10. Ascites 11. Pyrexia of unknown origin 12. Drug induced liver injury 13. Evalution of back ache 14. Renal artery stenosis 15. Acute kidney injury 17. Mircovascular and macrovascular complications of diabetes 18. Light's criteria 19. Metabolic acidosis 20. Iron deficiency anemia
Read more

Long case 1802102036

Image
  CASE OF ALTERED SENSORIUM SECONDARY TO DKA. 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT     A 50 year male farmer ,manual labourer,brought  to casualty with h/o altered sensorium since 1 day H/o fever since 4 days. HISTORY OF PRESENTING ILLNESS - Patient was apparently asymptomatic 4 days ago,then he developed fever which is high grade,No diurnal variation, associated with chills. No h/o cough and GE symptoms.  Attenders tells h/o stoppage of  OHA for 3days, h/o decreased intake of food as he has fever. H/o altered sensorium since 1 day. Irrelevant talk,not recognising attenders since this morning . Able to move all four limbs,No h/o vomitings, head ach
Read more

Prefinal examination answer sheet

Image
   1. Define Heart failure, Etiology And Clinical features of heart failure? How do we diagnose heartfailure clinically.Physical examination and various modalities used in diasnosis of heart failure Write a brief note of treatment of heart failure 2. Define Cirrhosis of liver. Etiopathogenisis of cirrhosis. Write a brief note on clinical features,diagnosis and treatment of cirrhosis of liver 3.  Elaborate on Clinical features and diagnostic modalities in diagnosis of Renal calculi 5.Diagnosis and Treatment of Dengue Fever 6. Clinical features und Diagnosis Peptic Ulcer Disease, 7. Treatment of Acute Pyelonephritis 8. Treatment of Abdominal Tuberculosis. 9. Etiology and treatment of pneumonia 10. Complications of Dialysis 11. Ascitic Fluid Analysis.  12. Proton pump inhibitors. 13. Aferload reducing agents in heart failure. 14 Treatment of urinary tract infections  5. Differential diagnosis of "Fever with Rash'. 16. Insulin therapy in diabetes mellitus, 17. Antihypertensive dru
Read more