A 40 year old with fever and vomitings

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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