Cheif complaints:

29 years old female surviving with 2 children resident of south asia

C/o indigestion 

C/o pain in the right hypochondrium

C/o weight loss in 6 months 

C/o giddiness since 6 months

C/o heart burn since 6 months


Hopi: 

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%


Systemic examination : 

Cardiovascular system : s1 , s2 heard , no murmurs

Respiratory system : b/L respiratory crepts in all lung fields.

P/a : soft , tenderness in the right hypochondrium on deep palpation , no organomegaly , bowel sounds +


Investigations :


HEMOGRAM: 

HB: 10.9

TLC: 5,900

N/L/E/M/B: 50/43/3/4/00

PCV: 33.8

MCV: 77.7

MCH: 25.1

MCHC: 32.2

RBC: 4.35

PLT: 2.77 

RDW-CV : 13.9

RDW-SD: 40.0

PS: NC/NC


RFT:

BLOOD UREA : 20  MG/DL

SERUM CREATININE: 0.7

SERUM ELECTROLYTES:

Na+ : 152

K+: 4.0

Cl-: 98


LFT

TB:0.77

DB: 0.16

SGOT:21

SGOT:19

ALP:269

TP:6.8

ALBUMIN:4.8

A/G: 2.34




ECG:            





Usg :


USG REPORT on 9/03/22

Liver abscess (+) 

Contracted gall bladder due to fasting 

Pt asked to come again tomorrow morning on empty stomach







USG REPORTS ON 10/03/22: 

FINDINGS:

• E/o Multiple tiny calculi in contracted gall bladder largest (M) 4-5 mm

• E/o 3.1X2.4 cm hypoechoic lesion in segment VI g liver & no internal vasularity & mild perilesional edema.

Review usg on 11/3/22 :

                        



IMPRESSION: 

• Cholelithiasis (review again in fasting state)
• Liver abscess in segment VI g liver with 20-30% liquefaction 




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