General medicine case discussion

B.Varshitha 
5th semester 
Roll no.21
This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 protfolio and your valuable inputs on comment box is welcome.


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 on and off fever (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 bought to the hospital through ambulance at early morning(6pm) there  symptoms were not subsided and they referred 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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