Final Practical long 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"










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.




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 and 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

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




No sign of clubbing, cyanosis


Icterus- present 


Bipedal edema present


 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 +




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






Cns- nad


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 

Clinical images









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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