This is an online E log book to discuss our patients deidentified 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 problems with collective current best evidence based inputs.

This E log book also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

CASE PRESENTATION:

A 50 year old male patient resident of suryapet came with chief complaints of pain in right hypochondrium (colicky type )and vomitings from 10 days. Associated with on and off low grade fever associated with chills ,relived on medication.

3-4 episodes of vomitings per day. Which was bilious , non projectile and food particles as content.

Taking treatment outside symptomatically in a local hospital from last 1 week and from there referred to our hospital.

No H/o Headache,giddiness,Loss of consciousness, blurring of vision.

No H/o loose stools,burning micturition.

No other complaints.

H/o similar complaints 1 year back- Diagnosed as cholelithiasis - s/p cholecystectomy.

Not a k/c/o DM ,HTN , Asthma, epilepsy, CAD, TB.

General examination:

Icterus +

No pallor,cyanosis,clubbing,lymphadenopathy,pedal edema.

Vitals:

Temp - 98.6F

PR - 110bpm , regular

BP - 110/70 mmHg

SpO2 - 98% @ room air



Systemic examination:

CVS - S1 S2 heard , no murmurs

RS - BAE + 

P/A -  Tenderness in right hypochondrium 

           Liver palpable (liver span 19cm )

CNS - NAD

Investigations:



Diagnosis : ?Alcoholic steatohepatitis.

Treatment:

Encourage oral fluids

IVF - NS , RL - 75ml per hour

INJ TRAMADOL 1AMP in 100ml NS @ 30min

INJ ZOFER 4mg iv sos

TAB PCM 650mg sos

INJ PAN 40mg IV stat

Tab BENFOMET PLUS OD

INJ TAXIM 1gm IV BD

INJ METROGYL 750mg IV TID


Temperature charting 4th hourly and tepid sponging

BP/PR/SPO2 monitoring.


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