1601006054 SHORT CASE

 

SHORT CASE

1601006054


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 :1601006054

A 61 year old male came to OPD with chief complaints of pain in abdomen& 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 84cm

 


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


USG Abdomen






Provisional diagnosis: Multiple 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 twicedaily





Comments

Post a Comment

Popular posts from this blog

  2K16 BATCH UNIVERSITY PRACTICAL EXAMS    DEPARTMENT OF GENERAL MEDICINE   DATE: 26.04.2021 (MONDAY) S. NO HALLTICKET NO CASE BLOG LINKS  CASE PRESENTATION VIDEO LINKS      1 1601006001 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006001-long-case-april-23-2021-hall.html SHORT CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006001-short-case-april-25-2021.html https://youtu.be/9xE26ZkzqDg 2 1601006002 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006002-long-case.html SHORT CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006002-short-case.html https://youtu.be/7jBj-Fz8kc4 3 1601006003 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006003-long-case-50-
Read more

1601006161 SHORT CASE

Image
  SHORT CASE : A 34-YEAR-OLD GENTLEMAN WITH CHRONIC KIDNEY DISEASE UNDERGOING DIALYSIS   HALL TICKET NUMBER : 1601006161 A 34-year-old gentleman, from Motukur, who is a labourer by occupation, came to the hospital on 17/04/2021, for Maintenance Hemodialysis. History of presenting illness : The patient was apparently asymptomatic 3 years ago, when he was diagnosed with  Hypertension, secondary to Chronic Kidney Disease.  He was regularly taking his medication for Hypertension, until he  abruptly stopped  doing so 2 months ago. The patient has been  undergoing maintenance hemodialysis at our hospital since the past 10 months . He complains of facial puffiness, abdominal distension and swelling in the legs.  The patient also complains of loss of weight over the past 3 years. Initially, he was 63 kg, now he is 52 kg. General Physical Examination : The patient is conscious, coherent and cooperative, lying supine on the bed He is well oriented to time, place and person. He is moderately buil
Read more

1601006168 SHORT CASE

Image
  MEDICINE SHORT CASE 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 is welcome." I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  CASE PRESENTATION: 34 year old male patient who is a labourer by occupation hailing from nalgonda came  to the OPD with a chief complaint of  Chest pain
Read more