A 40 year old with fever and vomitings




This is an online e log book
to discuss our patient de-identified 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 problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. is an online e log book to discuss our patient de-identified 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 problem with collective current best evident based input

K.Phani Keerthana 
Roll no 72
 
A 40 year old male agriculture labourer by occupation resident of chitiyal came to opd with chief complaints of 
Fever since 2 days
Vomiting since 1 day
 
HOPI- Patient was apparently asymptomatic 2 days back then he developed fever with chills and rigor sudden in onset and continuous 
Not relived on medication 

H/o vomiting associated with nausea since yesterday 1 episode.food particals as content non bilious and non projectile type
 
No h/o burning micturition
No h/o rash
No H/o abdominal pain and distension 
No h/o diarrhoea 
No h/o neck rigidity
No h/o night sweats
No h/o weight loss
He visited local hospital in chitiyal on the day of fever where the medication were given and the fever didn’t relieve.

Past history-
Not a known case of DM HTN thyroid epilepsy 

Family history-
Not significant 
 
Personal history-
 Diet- Mixed
Appetite- Normal
Bowel and bladder-regular 
Sleep- adequate 
Addictions-consumes alcohol and toddy occasionally 

General examination- patient is conscious coherent cooperative well oriented to time place and person moderately built and nourished 
Patients was examined in well lit room and consent was taken 
 
Vitals 
Pulse rate- 65bpm
B.P - 110/80
R.R 20/ min
SpO2-92%

                    



       
 
No signs of 
Pallor icterus 
Cyanosis 
Clubbing 
Lymphadenopathy 
Edema

Systemic examination- 
 Per abdomen- 
On inspection shape-normal
Umbilicus central 
No visible scars 
No engorged veins
All quadrants equally move with respiration 
No visible pulsations




Palpation- All inspectory findings are confirmed 
Soft and non tender
No organomegaly 
No rigidity

Percussion- No fluid thrill 

Auscultation- bowel sounds are heard

Respiratory system- ON inspection trachea, scar on right upper part of chest
   Palpation bilateral symmetrical expansion of chest
Auscultation- normal vesicular breath sounds 

Cvs -
Inspection - No scars or engorged veins
Palpation apex beat felt 
Auscultation- S1 S2 heard No murmers 
  
Cns- patient is consious coherent cooperative well oriented to time place and person.
Cranial nerves - intact
Sensory system- normal
Motor Tone power bulk reflexes are normal in all 4 limbs 

Fever chart- 
  
Provisional diagnosis - Fever under evaluation with thrombocytopenia and hypotension

INVESTIGATIONS- Hemogram
  RBS-  
Blood urea
 
Serum electrolytes 
L 
LFT-  
Dengue NS1 antigen- 
Widal  test  
 
Serum creatinine 
 
ECG-  

 
Treatment- I.V fluids (NS,ringer lactate)
                   Inj.neomol 
                   Tab dolo
                   Plenty of oral fluids
                    Tepid sponging 
                    Inj monocef 
                    Inj.Falcigo 

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