28 year old male with cough and epigastric pain

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 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 patients clinical problems with collective current based inputs.

CHIEF COMPLAINTS 

28 year old male came with the chief complaints of 

cough since 5 days and 

epigastric pain since 3 days

HOPI

Pt was apparently asymptomatic 5 days back then he had cough which was a dry type for 4 days and with sputum from today morning  which is whitish in colour,non foul smelling, non blood stained . Fever for 1 day which is low grade and more at night  relieved by taking medication.

Since 3 days  he has epigastric pain which is insidious in onset gradually progressive aggravated in suline position and relieved by sitting and leaning forwards associated with giddiness

No H/ O burning micturition, hematuria

PAST HISTORY 

N/K/C/O HTN , DM, TB, EPILEPSY, CAD, ASTHMA

DAILY ROUTINE

wakes up at 5:00 does his daily routines and goes to work ( in grampanchayath water department) And does not takes breakfast most of the days  and  takes lunch at 1: 00 pm and goes to work and returns home by 5: 00 and watches TV for some time and takes dinner by 9:00 pm and goes to bed by 10:00 

FAMILY HISTORY

not significant 

PERSONAL HISTORY 

Diet - Mixed

Appetite- decreased 

Bowel and bladder movements-passing urine regularly but did not pass stool  for 2 days

Sleep-adequate

Habits-started consuming alcohol since 10 yrs initially occassionally but from 6 years started consuming daily ( 1 quarter)


GENERAL EXAMINATION

Patient is conscious coherent cooperative, well oriented to time place person

moderatly built and moderately nourished 

 Pallor- mild 

icterus- absent

cyanosis- absent

clubbing- absent

Lymphadenopathy - absent

Edema- absent





VITALS 

 Bp - 100/70 mm hg

PR - 84 bpm

RR -20 cpm

GRBS - 130 mg/ dl





SYSTEMIC EXAMINATION

•CVS- S1, S2 heard

• RS- BAE  present 

• CNS - intact

•PA-

 ▪INSPECTION inspection- shape - schapoid and symmetrical

umbilicus- inverted and central in position
no visible scars, dilated veins

▪PALPATION- local rise of temperature in epigastric right hypochondriac, right lumbar, umbilicus area   tenderness in epigastric and  right hypochondrium , 
▪Hepatomegaly present, spleen not palpable
▪ no shifting dullness present
▪no palpable mass
▪Bowel sounds-heard







Day 2
































PROVISIONAL DIAGNOSIS 


? Amoebic liver abscess


TREATMENT

1) INI MAGNEX FORTE 1.5 MG 1V/ BD

2)INJ TRAMADIL 1amp in 100 mk IV OD

3)  INJ ZOFER 4 mg IV OD

4) INJ OPTINEURON 1 amp in 100 ml NS IV OD

5) IVF NS, RL @ 100 ml/hr






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