Case : Liver abscess and Cholelithiasis

This is an online E log to discuss our patients de identified health data shared after taking their signed  consent .
This is a case of 29year old female who came to hsopital on 9 march 2022 with complaints of pain in right hypochondrium .

CHIEF COMPLAINT :
Patient complains of Pain in upper abdomen

PATIENT HISTORY : 
Patient was apparently asymptomatic 6months back , then developed pain in right hypochondrium .
She had fever followed by the pain.
Has an history of indigestion.

PRESENT ILLNESS HISTORY : 

She is now presented with abdominal pain radiating to the back since few days . 
She has dragging type of pain . She is married and she had her first child 8years back .
 She had her second child  6months back . After her second child is born she started having this abdominal pain .
 She used to have self induced vomitings and was having indigestion at that time. 
She took medication for that indigestion and felt relieved instantly.
Now she is using the medication regularly . She had fever 2times in last 6months.
She went to local doctor for checkup on 22/2/2022.


PAST HISTORY : 
None 

DRUG HISTORY : 
Metronidazole 400mg
Pantacid
Novique 
FAMILY HISTORY :
 None
 
PERSONAL HISTORY :
Married 
Appetite : Normal
Bowels : Regular 
Micturition :  Normal

PHYSIOLOGICAL EXAMINATION : 

No pallor
No edema
Temperature : 98.5 F
Pulse rate : 99 
Respiration rate : 18 / min
BP : 110 / 90


SYSTEMIC EXAMINATION : 
CVS :
Cardiac sounds S1 S2 heard

ABDOMEN : 
Scaphoid
No tenderness
Liver : not palpable 

CNS : 
Level of consciousness : alert 
Speech : normal

PROVISIONAL DIAGNOSIS : 
LIVER ABSCESS  in segment 6 AND CHOLELITHIASIS 

INVESTIGATIONS :

Hemogram : 
Hb :   10.9 
TLC : 5,900
Leukocyte : 43
PCV : 63.8
MCV : 77.7
MCH : 25.1


ECG : 
Ultrasound report : 

USG :
Discussions : 

The patient was advised to have a surgery .









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