A 28 year old male with epigastric pain

A 28 year old patient with epigastric pain

September 28, 2022

Hi, I am U.Sravani, 3rd semester medical student. This is our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. This elog also reflects my patient centered online learning portfolio

A 28 year old male resident of Manimidhe presented to opd with epigastric pain.

CHIEF COMPLAINTS
Epigastric pain since 7 days which is associated with cough
Swelling in the right lower abdomen with puss discharge since 7 days

HISTORY OF PRESENT ILLNESS 
Patient is apparently asymptomatic 7 days ago
Then he had epigastric pain on the right side which is incidents on onset, gradually progressive which aggravates on leaning forward, sitting and coughing
It regressed on lying down 
Not relieved on medication
2 days back he had fever with no chills that subsided on medication.
No nausea

HISTORY OF PAST ILLNESS 
No HTN/diabetes

PERSONAL HISTORY
Patient is a farmer by occupation 
married
Bowel movement is regular
Burning Micturition
alcoholic

FAMILY HISTORY 
No significant family history 

PHYSICAL EXAMINATION 

A. GENERAL EXAMINATION

Well built
Well nourished
No pallor
No icterus
No cyanosis
No pedal oedema
No clubbing of fingers
No lymphadenopathy
Mild dehydration

B. VITALS

Temperature - Febrile
Pulse - 92 bpm
Respiratory rate - 17
BP - 110/80
GRBS - 88 mg%

SYSTEMIC EXAMINATION

 A. CVS
- No thrills
- S1 S2 positive
-no cardiac murmurs

B. RESPIRATORY SYSTEM 
- no dyspnoea 
- No wheezing
- central trachea
- vehicular breath sounds 

C. ABDOMEN
- palpable liver
- Bowel sounds

C. CNS
- conscious and coherent
- normal speech

INVESTIGATIONS

HEMOGRAM
- Hb - 14.9
- TLC - 13,000
- RBC - 14.82
- PLT - 3.2

USG
PROVISIONAL Diagnosis 
Amoebic liver abscess

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