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

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