1802102031 SHORT CASE FINAL PRACTICAL EXAMINATION

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.

35 year old male came to our hospital with chief complaints of upper abdomen pain since one week, fever since one week.

Patient was apparently asymptomatic 1 week ago, then developed pain abdomen which was insidious in onset, gradually progressive.

Pain in right hypochondrium and gastric region with no aggravating and relieving factors

Fever is on and off since one week, high grade not associated with chills and rigor, cold, cough, body pains, nausea, NJ vomitings, loose stools and constipation.

No history of bleeding manifestations.

PAST HISTORY:

Not a k/c/o T2DM,HTN,asthma , epilepsy,TB 

PERSONAL HISTORY:

Diet - mixed
Appetite - decreased since 1 week
Sleep- adequate
Bowel movements- normal
Addictions- alcohol, regular, since 10 years
Smoking, 10 pack years

General physical examination:

Pt is conscious, coherent, cooperative, 
Icterus- present 

 Vitals-

Temp- afebrile 
Bp-110/70 mm hg
Pr- 86 bpm
Rr-20 cpm
Spo2- 98% on RA

Systemic examination:

RS- bae+, nvbs
Cvs-S1 S2 +
P/A - tenderness + at right hypochondrium and epigastric region
Sluggish bowel sounds heard
Cns- nad




                    Ultrasound abdomen

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 


     Surgery referral

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

A 35 year old female with Pedal edema since 20 days, Decreased urinary output since 20 days, shortness of breath, Facial puffiness.

Image
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. CHIEF COMPLAINTS A 35 year old female came to casualty with  Bilateral pedal edema since 20 days, Decreased urinary output since 20 days, shortness of breath, and Facial puffiness. HISTORY OF PRESENTING ILLNESS
Read more

55 year old female with Uncontrolled Glucose levels.

Image
  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 55 year old female , daily labourer by occupation resident of Suryapet came for insulin dose fixation for eye surgery.She is a known case of Diabetes. HISTORY OF PRESENTING ILLNESS Patient was apparently as
Read more

60 YEARS OLD FEMALE PATIENT WITH HISTORY OF BURNING MICTURITION

Image
    60 YEARS OLD FEMALE     PATIENT WITH HISTORY OF          BURNING MICTURAITION CASE: DATE OF ADMISSION:02/08/2021 60 years old female resident of Hyderabad presented to the opd with chief complaint of burning micturaition since two weeks. HISTORY OF PRESENT ILLNESS: patient was apparently asympotmatic 14 days back then she developed low backache,followed by fever ,chills, with raised bp levels and developed  generalised weakness with burning micturaition. PAST HISTORY: she is having similar complaint every 6months since 6 years History of hysterectomy surgery No history of epilepsy,pedal edema Having DM since 25yrs   PERSONAL HISTORY: Appetite-less Diet-mixed No addictions Bowel and bladder movements-normal FAMILY HISTORY: No history of similar complaints in family  TREATMENT HISTORY: No history of  drug allergy. GENERAL EXAMINATIONS: Patient is coherent ,conscience and cooperative pallor-positive No icterus No  cyanosis No clubbing,lymphadenopathy Temp- BP-110/80 mm of Hg PR-95 BPM
Read more