general medicine final practical

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 box"




Ĺong case

35 year old male came to the opd  with chief complaints of upper abdomen pain since one week,fever since one week ,backpain since 4 days.


Patient was apparently asymptomatic 20 days back ,then he observed yellowish discolouration of eyes and got admitted to near by hospital and diagnosed as jaundice after investigations and taken medications ,later 1week back he developed pain in the abdomen which was insidious in onset, gradually progressive. Pain in right hypochondrium and gastric region which is aggrevated on sleeping during night and relieved during standing,4 days back he developed back pain ,which is dull aching type.

Fever is on and off since one week, high grade not associated with chills and rigor, cold, cough, body pains.

No history of nausea , vomiting,loose stools.

No history of bleeding manifestations.

No history of renal stones


PAST HISTORY


Not a k/c/o T2DM,HTN,asthma , epilepsy,TB .Had a hernia operation 8 years back 


PERSONAL HISTORY


Diet - mixed


Appetite - decreased since 1 week


Sleep- adequate


Bowel movements- dark stools 

Bladder -yellow urine with burning sensation


Addictions- alcohol,360 ml, regular, since 10 years


Smoking -20 cigarettes per day since 10years


General examination:


Pt is conscious, coherent, cooperative,well oriented to time ,place and person. 


No sign of clubbing, cyanosis

Icterus- present 

Bipedal edema present

 Vitals-


Temp- afebrile 


Bp-110/70 mm hg


Pr- 86 bpm


Rr-20 cpm


Spo2- 98% on RA


Systemic examination


RS- bae+ ,normal vesicular breath sounds 



Cvs-S1 S2 +, no murmurs heard


P/A - on inspection- 3 scars are seen , hernial orifices are normal 

Tenderness + at right hypochondrium and epigastric region



Cns- nad














Investigations
3/2/22
HB-10.2
TLC- 17,900
PLT- 5.1

Serum amylase- 60 
Serum lipase- 28

RFT
Serum urea- 37
Serum creatinine- 1.1
Sodium- 130
Potassium- 6
Chloride- 98

3/2/22
LFT
TB- 4.40
DB- 3.12
AST/ALT- 96/145
ALP- 586
TP- 5.3
Alb- 2.6
A/G- 0.94

PT -17 sec
APTT- 34 sec
INR- 1.25 


Diagnosis
Liver abscess secondary to ? Amoebic or pyogenic 

Plan of treatment 
1. INJ. METROGYL 750MG/IV/TID
2. INJ. MAGNEX FORTE 1.5MG/IV/BD
3. INJ. PAN 40MG/IV/BD
4. INJ.  THIAMINE1 AMP IN 100ML NS/IV/ OD OVER 30 MIN
5. INJ. TRAMADOL 1 AMP IN 100ML NS/IV/OVER 30MIN/ SOS
6. INJ. DICLOFENAC 3ML=75MG IM/BD
7. TAB. PCM 650 MG PO/QID
8. INJ. NEOMOL 1G IV/SOS





Short case



BLADDER CALCULI


A 70 year old female ,labourer by occupation came with chief complaints of

1)decreased urine output since 20days
2)burning micturition since 20 days
3)urgency and hesitency of micturition since 20 days
4)mass per abdomen since 15 days

The patient was apparently asymptomatic 20 days back ,then she noticed a decrease in her urine output , burning micturition,urgency and hesitency of micturition ,so she visited local hospital and investigations were done 
She denies h/o fever, loin pain, hematuria.

PAST HISTORY
She was hysterectomised 18 years back for fibroid uterus.
Not a k/c/o T2DM,HTN,asthma , epilepsy,TB 

PERSONAL HISTORY
Diet - mixed
Appetite - normal
Sleep- adequate
Bowel movements- normal

General physical examination
Pt is conscious, coherent, cooperative, 
 Vitals-
Temp- afebrile 
Bp-90/50 mm hg
Pr- 86 bpm
Rr-20 cpm
Spo2- 98% on RA

Systemic examination
RS- bae+, nvbs
Cvs-S1 S2 +
P/A - distended,tenderness + a hard mass of size 12x8 cm palpable in the suprapubic region.
Cns- nad






X RAY ERECT ABDOMEN

ECG

ULTRASOUND ABDOMEN



INVESTIGATIONS






DIAGNOSIS
UROSEPSIS secondary to b/l hydro ureteronephrosis with Bladder calculi with AKI  with UTI.

PLAN OF TREATMENT
Tab.NITROFURANTOIN 100 MG OD
Tab.OROFER XT  PO OD
Tab. NODOSIS 500 MG PO BD
Tab.SHELCAL PO OD
Tab. LASIX  20 MG PO BD






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