[13-04-2025 20:28] PPM 3: C/o pain at the left hypochondrium since 17 days
C/o fever since 15 days
Pt was apparently normal 20 days then after a traumatic psychological event (death of a relative) patient consumed alcohol and slipped and fell, on the left side, no loss of consciousness, got up by himself and went home. He was apparently fine for 3 days, then suddenly he developed pain at the left hypochondrium, non radiating, stabbing type, not relieved by rest and also developed fever, high grade, intermittent, 2 episodes one at morning, one at evening, subsided by medication. He visited a local hospital, then on the 5th day he went to a different hospital. Because he had 1 episode of blood stained stool, watery in consistency, no h/o vomitings or nausea and was also having pain at the left hypochondrium and fever again, and shortness of breath, sudden onset, grade-2, resolved. After two days h/o burning micutrition where they found he had a 9 rib#,? Minimal hemothorax and raised urea and creatinine levels
Past history:
N/c/o DM, HTN, CVA, CAD, TB, Epilepsy, Thyroid disorder
Personal history:
Appetite normal
Mixed diet
Intermittent burning micutrition
No known allergies
Occasional alcohol consumer (90 ml once in a month)
No significant family history
Pt was conscious, coherent, cooperative
Mild pallor
Icterus (+)
No Icterus, Cyanosis, Clubbing, lymphadenopathy, Edema
Temp:98.6°F
Pr:80b/min
Bp:140/90 mmHg
Spo2:93% on RA
Grbs:200 mg/dl
P/A: Soft, tenderness present at the left lumbar region
Liver function tests
Total bilirubin:2.88
Direct bilirubin:1.81
Ast:24
Alt:58
Total proteins:5.2
Albumin:2.5
A/G ratio:0.95
06-04-2025
[13-04-2025 20:30] PPM 3: 8/4/25
[13-04-2025 20:30] PPM 3: Yes, they have told that the splenorenal space collection is connecting with the cyst in kidney.
[16-04-2025 15.45] PPM 1: Update: Getting discharged today
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