A 50 year old male patient with a complaint of abdominal pain

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's 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.
Chief complaint 
A 50 year old male patient farmer by occupation came to the casuality with the chief complaints of abdominal pain since 1 month
HISTORY OF PRESENT ILLNESS :

Patient was apparently asympomatic 1 month back, then he developed abdominal pain after consumption  of food  in epigastric region.  Squeezing type of pain,non radiating,increases after consumption of food relieved on its own.
No history of fever ,weightloss,vomitings, diarrhoea and constipation 

HISTORY OF PAST ILLNESS :

N/k/c/o DM, HTN, Asthma , epilepsy, TB . 
No history of similar complaints in the past.

PERSONAL HISTORY :

Diet - Mixed
Appetite - Normal 
Sleep - Adequate 
Micturition-normal
Bowel and bladder movements- Regular
Addictions  -Patient consumes alcohol since 30 years
Zsmokes cigarette (8-10) or full pack since 30 years 
chews pan (3-4 times )daily.


FAMILY HISTORY :

No significant family history 

DRUG HISTORY :
No allergies to known drugs 
NO history of previous medication 


GENERAL EXAMINATION :


Patient was conscious, coherent, cooperative and well oriented to time place and person
Patient was well nourished and well built.
No H/o pallor, icterus, cyanosis,generalised lymphadenopathy, clubbing of fingers ,pedal edema
VITALS:-
Temperature: afebrile
Pulse rate:88 bpm.
Respiratory rate:16 cpm
Blood pressure: 120/80 mm Hg

SYSTEMIC EXAMINATION :

ABDOMEN-:  By taking consent from the patient examined in a well lited room 

Inspection:
Shape of the abdomen- Scaphoid
Flanks: flanks are free
Umbilicus- central and inverted.
no  sinuses and scars are seen.
No engorged veins 

Palpation:
No local rise of temperature 
No tenderness 
No palpable mass
No organomegaly.

Percussion:
No Fluid thrill
No shifting dullness
Tympanic note on percussion of abdomen

Auscultation:
Bowel sounds are heard
RESPIRATORY SYSTEM :

Chest is bilaterally symmetrical
Trachea is central
Movements with respiration are equal on both sides
Bilateral air entry present
Resonant sounds on percussion

CVS :
S1&S2 heard
No murmurs

CNS-:
  Consious, coherent ,cooperative 
   Speech normal
   No neck stiffness
   Motor system normal
   Sensory system normal
   Able to percieve-:pain , temp.
   Cranial nerves : intact

 PROVISIONAL DIAGNOSIS :
 
 Gastritis
 Cholelithiasis
 Cholecystitis
 Liver disease 
 
INVESTIGATIONS:
Complete blood picture

USG abdomen

FINAL DIAGNOSIS:
Liver abscess

TREATMENT: 
T pan 40 mg po/od

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