This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have 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 diagnosis and treatment plan.
35 year old male came to our hospital with chief complaints of upper abdomen pain since one week, fever since one week.
Patient was apparently asymptomatic 1 week ago, then developed pain abdomen which was insidious in onset, gradually progressive.
Pain in right hypochondrium and gastric region with no aggravating and relieving factors
Fever is on and off since one week, high grade not associated with chills and rigor, cold, cough, body pains, nausea, NJ vomitings, loose stools and constipation.
No history of bleeding manifestations.
PAST HISTORY:
Not a k/c/o T2DM,HTN,asthma , epilepsy,TB
PERSONAL HISTORY:
Diet - mixed
Appetite - decreased since 1 week
Sleep- adequate
Bowel movements- normal
Addictions- alcohol, regular, since 10 years
Smoking, 10 pack years
General physical examination:
Pt is conscious, coherent, cooperative,
Icterus- present
Vitals-
Temp- afebrile
Bp-110/70 mm hg
Pr- 86 bpm
Rr-20 cpm
Spo2- 98% on RA
Systemic examination:
RS- bae+, nvbs
Cvs-S1 S2 +
P/A - tenderness + at right hypochondrium and epigastric region
Sluggish bowel sounds heard
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
Surgery referral
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
Goji Berries... yes... I tried those too.For my health conditions, Those sweet, red berries seemed to help, but only during the time when I consumed them. I don't want to take a drug for the rest of my life, so why would I want to take a natural supplement everyday for the rest of my life (although Goji berries are very tasty and are highly nourishing). To me this was not a cure either (and I'm LOOKING for the CURE).
ReplyDeleteUp to that point, I hadn't found a cure. I felt like a young jumbled mess. I continued to have extreme pain, but continued on my path to healing. I started to focus on myself and not everyone else. When I was a young adult, I took on too much responsibility out of a sense of obligation. This was no longer healthy for me, so I resigned from all my projects and groups. Those days to come were the best [and worst] days. I took a lot of time off work, yet began to feel so extremely exhausted. Many health professionals "diagnosed" me with adrenal fatigue & Hiv,Prostate Cancer so my situation was annoying then I keep searching for permanent cure online that's when I came to know of Dr Itua herbal center hands whom god has blessed with ancestral herbs and a gift to heal people with diseaseSo I made a purchase of his herbal medicines and I have been watching my health for 6 years now and I actually confirmed that his herbal medicines are a permanent cure and I'm so happy that I came to know of his herbal healings.You can contact Dr Itua herbal center Email: drituaherbalcenter@gmail.com www.drituaherbalcenter.com if you went through exactly what I go through in terms of health conditions because to be honest there is more to learn about natural herbs than medical drugs.