28 year old male with fever chills and vomiting

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 .

K. Phani Keerthana

Roll no 72

A 28 year old male presented with fever chills and vomiting
HOPI- Patient was apparently asymptomatic 1 year back then he had burn injury over left great  toe lead to ulcer formation on Routine investigation diagnosed as DM 
Since 2 weeks patient had fever which was intermittent  a/w chills and vomiting 3-4 episodes, non bilious,non foul smelling
H/o yellowish discoloration of urine
Dry cough since 3 days 
No h/o abdominal pain
 
Past history- No similar complaints in past 
H/o  Diabetes - tab metformin b/d

Family history-not significant

Personal history- 
Diet - mixed 
Appetite- normal
Bowel and bladder- regular
Sleep adequate
Addictions-No
No h/o burning micturation

GENRAL EXAMINATION:


Patient is conscious coherent and co operative well oriented to time place and person. 

Patient was examined in a well lit room and consent was taken.

Vital -

PR-75bpm

BP-110/70

RR-16cpm

SPo2-98%

Temp-Afebrile

Pallor - Absent

Icterus - absent

Clubbing - Absent

Cyanosis- Absent

Lymphadenooathy- Absent

Edema - absent

Systemic examination-

SYSTEMIC EXAMINATION-

CVS-

S1, S2 heard

Resp

NVBS

CNS-

NFD

PER ABDOMEN-

Soft and non tender

Investigation 

Haemogram

CUE-

Feverchart-





Urine protein creatine ratio


USG-

ECG-


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