29 year old female with pain in right hypochondrium

This is an online E log book to discuss our patient deidentified health data shared after taking his/her/guardians signed informed consent 
Here we discuss our individual patient’s problem through series of inputs available global online community of experts with an aim to solve those patient’s clinical problem with collective current best evidence based inputs 

A 29 year old female patient came to hospital with pain in upper abdomen
CHIEF COMPLAINT 
Pain in the upper abdomen 
HISTORY OF PRESENT ILLNESS 
Pain from abdomen is radiating to back since few days 
Abdominal pain started after she conceived her second child . She also has problem of indigestion after taking medicine she felt relieved 
Went to local doctor on 22/2/22
HISTORY OF PAST ILLNESS 
Patient was asymptomatic 6 months back and then she developed pain in right hypochondrium 
Has an history of indigestion and also has self induced vomitings
Patient is conscious 

PERSONAL HISTORY 
Married
Occupation: house wife
Apetite: normal
Bowels: regular 
Micturition: normal 
FAMILY HISTORY 
Not significant 
PHYSICAL EXAMINATION 
No pallor , edema
Temperature:98.5F
Pulse rate: 99/min
Respiration rate : 18/min
Bp:110/90 mmhg
SYSTEMATIC EXAMINATION 
Abdominal examination
Shape: abdominal
No tenderness 
Liver not palpable
CVS
Cardiac sounds : S1 S2 heard 
Speech:normal
Cns- level of consciousness:alert
PROVISIONAL DIAGNOSIS 
Liver abscess in segment 6 and cholelithiasis 
Medication : T pan 40 mg 
                      Drotaverin 70 mg. 


She has advised to have a surgery 
Pain is radiating to back because gall stones blocked the bile ducts because of which pressure is increased and the pain is radiating to back.

















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