general medicine

29 years old female with 2 children


Chief complaint:-

 indigestion 

 pain in the right hypochondrium

 weight loss in 6 months

giddiness since 6 months

heart burn since 6 months

 

She was apparently asymptomatic 6months back , after her normal vaginal delivery she started complaining of indigestion and pain in the right hypochondrium(more during nights)and while eating food , after that her mother observed she was lossing the weight then they went to the public hospital and used medication for 5 months and they advised for usg abdomen . 

usg suggestive of abscess and gall stones - advised for admission but they refused to admit 

Not associated with nausea but she used to self induce vomiting 

Giddiness - non postural not associated with vertigo and  tinnitus or ear fullness 


Past history :

Not a k/c/o dm , htn , epilepsy , tb .


Personal history:

Diet : decreased intake of food i/v/o pain abdomen and indigestion 

Appetite: normal

Bowel and bladder moments : regular

Sleep : adequate

No addictions


Family history : 

No significant family history



O/e :

Patient was c/c/c

No signs of pallor , ictreus, clubbing , Sinuses lymphadenopathy , pedal edema.


Vitals :

Bp : 130/70mmhg

Pr :  86bpm

Rr : 16cpm

Spo2 : 97%

ECG :


Renal function test:

BLOOD UREA : 20 MG/DL

SERUM CREATININE: 0.7

SERUM ELECTROLYTES:

Na+ : 152

K+: 4.0

Cl-: 98


Liver function test:

TB:0.77

DB: 0.16

SGOT:21

SGOT:19

ALP:269

TP:6.8

ALBUMIN:4.8

A/G: 2.34

ULTRASOUND : abdomen


Diagnosis:

• Cholelithiasis (review again in fasting state)

• Liver abscess in segment VI g liver with 20-30% liquefaction 

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