General medicine case 1

Date of admission: 05/08/2021

26 year old man who is a daily wage worker came to causality with the cheif complaints of fever since 3months,cough since 2 months,dysponea on excretion since 2months  

History of present illness:

Patient was apparently asymptomatic 3 months back. Patient had a habit of consumption of 8 beers  after getting back home he experienced high fever. Then he went to local hospital and  on checking tempearture it was 104 °F for which he received medications for 2 days.  
Since 2 months he has been experiencing cough and  dyspnoea on exertion .
Associated with vomiting - 3 episodes per day, containing food particles and blood .
Loss of weight since  2 months 
Loss of appetite since 2 months 
Dark stool since 3 weeks 
Patient visited 4 hospitals but was not relieved from his symptoms .  

Past history : 

No h/o similar complaints in the past .
No h/o Diabetes mellitus 
No h/o astama
No h/o hypertension
No h/o tb , epilepsy

Personal history: 

Diet - mixed
Appetite- normal
Sleep- adequate 
Bladder and bowel movements- regular 
Addictions - He has habits of alchohol and smoking occasionally. 

Family history:
  No history of similar complaints in family .

Drug history:
   No allergy to known drugs. 

General examination. 
  Patient is conscious,coherent and cooperative. 
Pallor present 
No signs of cyanosis 
No lymphadenopathy
Malnutrition is present 
No clubbing 
No edema 
No icterus 

Vitals:-
Temperature:-98.6°F
Bp:-110/70mm/hg
Pulse rate:-98bpm
Respiratory rate:-20Cpm

Systemic examination:-
 Cardiovascular system
S1 ad s2 sounds are heard 

  Respiratory system :
Position of trachea-normal
Bilateral air entery is normal
Normal vesicular breath sounds-heard 
No added sounds. 

Per abdomen:
Abdomen is distended,hard and tender in epigastric,Right hypochondriac region.

Bowel sounds heard.

CNS
Patient is conscious.
Speech is present. 
Reflexs are normal .

 Provisional diagnosis:
  Liver abscess?
  Cirrhosis of liver?

 INVESTIGATIONS :
   Serology :
  



Hemogram:

APTT:

PT:

Blood grouping:

ESR:

Bleeding and clotting time:

LFT:
Serum uric acid:

Serum electrolytes:



Serum creatinine:

Blood urea:
ECG:


Ultrasound abdomen:


Final diagnosis:
     Liver mass

Treatment:

Day 1 

IVF ( 20 NS @ 75ml/ hr)      

IVF  1 amp Optineuron

Inj Augmentin  1.2g/ IV / BD 

Inj  Pantop 40mg IV /OD 

Inj Zofer 4mg IV /TID 

Tab Dolo 650 mg ( SOS) 

Syp Ambroxyl 10 ml ,TID 

Day 2 

Inj Metrogyl  TID

Inj  Zofer ,TID

IV fluid -NS ,TID 

Inj monocef  1g /BD 

Syp Ambroxyl 10 ml ,TID 

Day 3 & 4 

Inj monocef  1g BD 

Inj  zofer 4mg/IV TID 

Inj  Pantop 40mg IV /OD

Inj 1 amp Optineuron IV/ OD

Inj Metrogyl 100ml /IV  TID 

Tab .Dolo 650mg (SOS) 

Tab.Paromomycin 500mg

Day 5

Inj.metrogyl 750mg iv tid  

Inj monocef  1g BD 

 Inj  zofer 4mg/IV TID 

Inj  Pantop 40mg IV /OD

Inj 1 amp Optineuron IV/ OD

Tab.Diloxinide furoate 500mg po tid

Tab.ultracet 1/2 tab pro Qid

 

Questions 

  1.What are the complications of liver abscess?


  2. What happens if a liver abscess bursts?

   

   3. How long does a liver abscess take to drain?


    


Comments

Post a Comment

Popular posts from this blog

GM case 9

Image
  This is an 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 patient's 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 the comment" A 27 year old male who is student from nalgonda came to the opd with chief complaints of pedal edema  since 2years . He also had vomiting and decreased urine output since 1mon History of present illness:   Patient was apparently asymptomatic 2yrs back then he developed persistent vomiting for about 2mon ,then he noticed bilateral pedal edema of pitting type which is insidious in onset ,for which he visited to local hospital and got to be told have some kidney issue and received med
Read more

GM CASE 6

Image
  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 inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome". K.meghana 39 , k.Sai likhitha 37  Date of admission:18/09/2021  39 years old male who doesn't have any proper occupation came with the chief complaints of abdominal discomfort and SOB since 3days.   History of present illness:   Patient has similar complaints since 5 years . Before diagonosing he had fever and loss of appetite since 1mon and also with cough, cold and throat infection along with back pain  and he visited local hospital where they identified is creatinine hig
Read more

GM CASE 8

Image
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 inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome".  A 60 year old Male who is a labour by occupation visited our opd which chief complaints of fever and cough since 15 days . History of present illness:   Patient was apparently asymptomatic 3 years  back then  he developed fever associated with chills which is intermittent and also dry cough .He joined our hospital it got reduced and he discharged.before 15 days he again developed  high grade fever associated with  Loose stools,low backache, burning micturation,sob.  No h/o abdom
Read more