50year old male patient with abdominal pain.

50 year old male patient with abdominal pain.

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

Date of admission: 16-01-2023.

Cheif complaint: A 50 year old male, farmer by occupation came to the casuality with the chief complaints of abdominal pain since 1 month(Dec 4th).

HOPI: Patient was apparently asympomatic 1 month back, then he developed abdominal pain after consumption of food on 4th December 2022 in epigastric region and right hypochondrial region.
Squeezing type of pain, non radiating, increases after food consumption and after lifting heavy weights relieving on its own. Pain lasts for 30 minutes during the episode. Patient feels a bit feverish during the episode.
No h/o weight loss
No h/o vomitings
No h/o diarrhoea or constipation 
No h/o loss of appetite 
No h/o fever
No h/o blood in stools
No h/o burning micturition
No h/o shortness of breath
No h/o regurgitation of food.

History of past illness: 
No similar complaints in the past.
N/k/c/o Hypertension, DM, Asthma, Epilepsy, CAD, TB.

Personal history:
-Diet - Mixed
-Appetite - adequate 
-Bowel and bladder movements- Regular
-Sleep- adequate.
-Addictions - Patient consumes alcohol occasionally ( 25ml) , smokes cigarette
8-10 or a box full per day, chews khaini and betel leaf(pan) 3-4 times daily.

Family history:
-No significant family history.

General examination:
-Patient was examined after taking his consent.
-Patient was conscious, coherent, cooperative, well oriented to time place and person, well nourished and well built.
-Pallor- Absent
-Icterus- absent
-Clubbing- absent
-Cyanosis- absent
-Lymphadenopathy - absent
-Edema- absent.

Vitals:
-Temperature: afebrile
-Blood pressure:130/80mmhg
-Pulse rate:88 bpm.
-Respiratory rate:16 cpm.

Systemic examination:
GIT examination:
Inspection:
-Oral cavity- No dental caries,  stains present.
-Abdomen:
-Shape of the abdomen- Scaphoid
-Flanks: flanks are free
-Umbilicus- centrally placed and inverted.
-Sinuses and scars- no visible sinuses and scars are seen.
-Dilated Veins- no visible veins 
-No visible peristalsis or no visible pulsations
-Straie - no visible straie.
-All quadrants moving equally on respiration.

Palpation:
-Done in supine position with hands by side of the body.
-No tenderness or local rise in temperature.
-Abdomen- soft
-No rigidity is felt.
-No palpable mass
-No organomegaly.

Percussion:
-Tympanic note is heard all over the abdomen.

Auscultation:
- Bowel sounds are heard.

Respiratory examination:
-Chest is bilaterally symmetrical.
-Movements with respiration are equal on both the sides.
-Trachea appears to be in center.
-No kyphoscoliosis.
-Normal Vesicular breath sounds are heard.

Cardiovascular examination:
- Elliptical & bilaterally symmetrical chest
- No visible pulsations/engorgedveins/scars/sinuses on the chest wall
- Apex beat palpable at 5th intercostal space medial to midclavicular line 
- S1 , S2 heard
- No murmurs.

CNS examination:
-No focal neurological deficets .
-Speech is normal.
-Memory is intact.
-Higher mental functions -intact.

Provisional diagnosis:
Liver disease.

Investigations:
Ultrasound report-16-01-2023.
Hemogram- 17-01-2023.

Final diagnosis: liver abscess.

Treatment: T pan 40 mg po/od.









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