general medicine elog

 Anahita Behara 

roll no.08

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 .

Case discussion

A 55 year old male resident of Nunavathanda came to opd with
Chief complaint of
Pain abdomen at right hypochondrium and lumbar region , decreased appetite & SOB (shortness of breath) since 20 days for which he went to a local hospital and diagnosed as Multiple liver abscess(? Pyogenic)-unliquified and treated with IV antibiotics.

No H/O Fever,vomitings,loose stools,no other complaints
H/O TB 10 years back used medications for 5-6 months
Not a k/c/o HTN,DM, Asthma,CAD.


Treatment history
He used medications for TB 10 years back for 5 months.


Personal history;
Diet:Mixed
Appetite:Normal
Sleep:Regular
Bowel and bladder:Regular
Occupation: farmer
Patient consumes 180 ml of alcohol daily since 40 years
He smokes sutta 3/day since 40 years

O/E:
Pt c/c/c
PR: 86 bpm
BP:110/80 mmhg
CVS: S1 S2 + , no murmurs
RS: BAE + , NVBS
P/A: soft , Tenderness + in right hypochondrium
CNS: NFND

Investigations

serum electrolytes:

serum creatinine:
blood urea
hemogram:

liver function test:


ECG of patient:

Ultrasound report:









Diagnosis:
Multiple liver abscess (?pyogenic)

Treatment on
1/07/21(day1)-
Inj.MEROPENAM 1gm IV/BD
INJ.METROGYL 100ml NS IV/TID
INJ.TRAMADOL 1amp in 100ml NS IV/OD
BP/PR/Temp/SpO2 monitering

current status of patient ; DISCHARED on 3rd of july 

// information was presented with the help of dr.Biswas and Dr.pavan (intern)

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