Short case

1601006047


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


HALL TICKET :1601006047

A 61 year old male came to OPD with chief complaints of pain in abdomen since 10 days , distension of abdomen since 10 days , fever since 2 days. 


 History of presenting illness: 


Pain is diffuse, progressive, dragging type  and is relieved by sleeping sideways. 

 abdominal distension associated with edema of legs(pitting type)

fever since 2 days low grade continuous associated with chills and rigor.


 General examination : 

 Presence of icterus 

 Presence of pedal edema 








Abdominal Examination : 


Inspection: 

Abdomen is symmetrically distended with full flanks 

Umbilicus is everted with slight horizontal slit 

 Abdominal girth is 84cms

 


Palpation:


Superficial palpation: Localised tenderness in the right hypochondrium

Deep palpation: liver is tender, smooth,firm,regular margins, moving with respiration , not able to insuate fingers under the coastal margin.


Percussion : 


Liver span:16 cms 

No shifting dullness


Investigations: 

1. Complete blood picture

2.LFT







Provisional diagnosis: Multiple  pyogenic liver abscess


Treatment: 

inj meropenem500mg i.v BD

Inj Metrogyll750mgi.v  Tid 

Tab doxycycline100mg oraltwice daily

Tab lasix 40mg orally once daily

Syrup lactulose 15ml orally







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