blog 5

Date:28/11/22

This is an online E- log book to discuss our patient's de- identified health data shared informed 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 comment box is welcome."

Chief complaint:

29 years old female surviving with 2 children resident of suryapet. 

C/o indigestion 

C/o pain in the right hypochondrium

C/o weight loss in 6 months 

C/o giddiness since 6 months

C/o heart burn since 6 months

History of present illness:

She was apparently asymptomatic 6months back , after her normal vaginal delivery she started complaining of indigestion and pain in the right hypochondrium(more during nights)and while eating food , after that her mother observed she was lossing the weight then they went to the public hospital and used medication for 5 months and they advised for usg abdomen . 

usg suggestive of abscess and gall stones - advised for admission but they refused to admit 

Not associated with nausea but she used to self induce vomiting 

Giddiness - non postural not associated with vertigo and  tinnitus or ear fullness 


Past history :

Not a k/c/o dm , htn , epilepsy , tb .


Personal history:

Diet : decreased intake of food i/v/o pain abdomen and indigestion 

Appetite: normal

Bowel and bladder moments : regular

Sleep : adequate

No addictions


Family history : 

No significant family history



O/e :

Patient was c/c/c

No signs of pallor , ictreus, clubbing , Sinuses lymphadenopathy , pedal edema.


Vitals :

Bp : 130/70mmhg

Pr :  86bpm

Rr : 16cpm

Spo2 : 97%


Systemic examination : 

Cardiovascular system : s1 , s2 heard , no murmurs

Respiratory system : b/L respiratory crepts in all lung fields.

P/a : soft , tenderness in the right hypochondrium on deep palpation , no organomegaly , bowel sounds +


Investigations :


HEMOGRAM: 

HB: 10.9

TLC: 5,900

N/L/E/M/B: 50/43/3/4/00

PCV: 33.8

MCV: 77.7

MCH: 25.1

MCHC: 32.2

RBC: 4.35

PLT: 2.77 

RDW-CV : 13.9

RDW-SD: 40.0

PS: NC/NC


RFT:

BLOOD UREA : 20  MG/DL

SERUM CREATININE: 0.7

SERUM ELECTROLYTES:

Na+ : 152

K+: 4.0

Cl-: 98


LFT

TB:0.77

DB: 0.16

SGOT:21

SGOT:19

ALP:269

TP:6.8

ALBUMIN:4.8

A/G: 2.34




ECG:            

Usg :


USG REPORT on 28/11/22

Liver abscess (+) 

Contracted gall bladder due to fasting 

Pt asked to come again tomorrow morning on empty stomach







USG REPORTS ON 29/11/22

FINDINGS:

• E/o Multiple tiny calculi in contracted gall bladder largest (M) 4-5 mm

• E/o 3.1X2.4 cm hypoechoic lesion in segment VI g liver & no internal vasularity & mild perilesional edema.

Review usg on 29/11/22.

                        



IMPRESSION: 

• Cholelithiasis (review again in fasting state)
• Liver abscess in segment VI g liver with 20-30% liquefaction

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