55yr old female with fever, abdomen pain.




ROHITH SOMANI


MBBS 9th semester 

roll no:127

This is 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 patients 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 comment box is welcome .

 

I’ve 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::

55 yrs old female came to opd with chief complaints of FEVER since 7 days and  abdominal pain since 4 days shortness of breath since 4days.

History of present illness:

Patient was apparently asymptomatic 7 days back then developed fever which was insidious in onset intermittent not associated with chills and rigor relieved on medications
Not associated with vomitings,loose stools

Abdominal pain  which more in right upper quadrant is insidious in onset, gradually progressive initially  pain  is  in right upper quadrant now radiating towards right and back stabbing type of pain no relieving and aggrevating factors

Shortness of breath is insidious in onset gradually progressive grade 1-2

Routine history:

Patient was a daily wage worker by occupation her daily routine was not disturbed on daily before onset of fever then abdominal pain which was severe during yesterday so admitted at hospital

Past history::

No similar complaints in past
No history ofDM,HTN,epilepsy,TB

Personal.history::

Appetite ::loss of appetite
Diet.mixed
Bowel and bladder..regular
Addictions..occasionally toddy 
No history of allergy to food or drug

Family history::
Insignificant

General examination::::

Patient was examined in a well light room with prior consent

Built:moderate
Nousihment:moderate
No pallor,mild icterus,no cyanosis,no clubbing ,no koilonychia ,no LYMPHADENOPATHY












Vitals::
Bp .120/80mm of Hg
RR..23c/min
Pulse rate..120beats/min
Temperature:99 f

Systemic examination:::

Abdominal::

Inspection.. 

Shape of abdomen...scaphoid
Umbilicus..inverted,central located
No sinuses or scars on abdomen

Palpation::

No rise in temperature
Tenderness present over right upper quadrant hypochondrium and epigastrium
No palpable mass 
No free fluid
Liver palpable and tender
Spleen not palpable

Percussion::

Dull note on right upper quadrant
No fluid thrill
No shifting dullness

Auscultation::

Bowel sound heard

Respiratory system::

Inspection::

Shape of chest ::bilaterally symmetrical
No scars and sinus on  Chest
No drooping of shoulder

Palpation::
 Inspectory findings confirmed
Apex beat felt at5th IC space medial to midclavicular line 

Percussion;;

Dull note on infrascapular area

Auscultation::
 Mild Crepts heard in infrascapular area

Cvs:::

S1,s2 heard
No murmurs
No thrill

CNS....

Conscious
Speech normal 
Neck stiffness.no
Kernigs sign.no
Sensory system:intact
Motor system:::
Reflexes..normal
Power of LL,uL...5/5

Investigations::
 
Comple.blood picture...

HB..11.3gm/dl
TLc.30000cells/mm3
Platelets::2.65lqakhs

RFt..
Urea..73mg/dl
Creatinine.1.7mg/dl
Na..137meq
K.4.2
Cl.95

LFt

Total bilirubin..2.55
Direct bilirubin.1.08
SGOT.41
SGPT.37
ALP..1022  Totalnprotien.5.9
Total albumin.1.72
A/g.0.42

RBS.122mg/dl
 
ECG:
     

Ultrasound abdomen.

1.liver abscess with hepatomegaly
2.raised echogenicity of b/l kidneys

on 12/01/2022
4pm..mild ascites detected




Provisional diagnosis:::
Abdominal pain 
Liver abscess

Management::

Inj.ceftriaxone 1g /iv/bd
Inj Metrogyl 750mg 
Inj.tramadol 
Inj.pan 40 od
Inj.zofer 
Intravenous fluids NS,RL ,DNS 




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