GENERAL MEDICINE E-log

 NAME : A SANVITH

ROLL NO : 09

DATE OF ADMISSION:29/06/2022

This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

QUESTION 

A 57 year old male patient came to the hospital with cheif complaints of fever since 6days and pain abdomen since 4days


History of present illness 

Patient was apparently asymptomatic 6days back then he developed fever which is intermittent type (morning and night) and 4days back he developed severe pain in abdomen in epigastric and right hypochondrium region and nausea after 2hours of dinner not associated with vomitings and cough for which he admitted in hospital early morning where symptoms are not subsided and therefore came here 
H/O decreased urine output is present 
No H/O weakness 
No H/O burning micturation 

History of past illness 

N/K/C/O HTN,
 Diabetes,
epilepsy,
TB,
asthma


Personal history 

• Diet : mixed
• Appetite: normal 
• Sleep : adequate 
• Bowel habits: normal 
• Bladder habits : decreased urine output 
• Chronic alcoholic(daily) since 30-40years 
   Smoker 10 cigarette/day since 30-40years 


Family history 

NO H/O HTN, Diabetes,epilepsy,TB,asthma


Physical examination 

General examination 

• No pallor
• Icterus is present 
• No cyanosis
• No lymphadenopathy
• No clubbing of fingers
• Moderately built and moderately nourished.






Vitals

Temperature: Afebrile 
Pulse rate: 74/min
BP: 110/80
RR:22/min


SYSTEMIC EXAMINATION

CVS

S1,S2 Heard
No murmurs

RESPIRATORY SYSTEM

No Dyspnea
No wheezes
Trachea-Central
Breath sounds-vesicular

ABDOMEN

Abdomen :obese
tenderness present in epigastric and right hypochondrium region
No palpable mass
No free fluid 
No briuts
No palpable spleen and liver


CNS

Conscious
Coherent
Cooperative
Speech-normal
No neck stiffness
Sensory system- Normal
Motor system- normal

Provisional diagnosis: Liver abscess with cholelithiasis


Investigations

ECG


2D ECHO


ULTRASOUND 


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