A 40 year old with fever and vomitings

January 03,2023


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


M .Vamshi krishna 
Rollno:99

A 40 year old male agriculture labourer by occupation came to opd with CHIEF COMPLAINTS:
Fever since 2 days
Vomiting since 1 day
 
HISTORY OF PRESENTING ILLNESS - 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 HOSTORY 
 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- 65 bpm
B.P - 110/80
R.R 20/ min
SpO2-92%
FEVER CHART :https://drive.google.com/uc?export=view&id=1zGd39FA2TUF7Bzh3JLaxQSZWcJ5KP_Or




https://drive.google.com/uc?export=view&id=1VinkpBo0yPi7uoc0J2XqHVWJY8zwgzZmhttps://drive.google.com/uc?export=view&id=1Mqkd0uDDJHhQe-XqqOITCeP-RY1HxaRQ
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

https://drive.google.com/uc?export=view&id=1oXHRJlgrDanyZmKvm4VLxG92dQGrZjBzhttps://drive.google.com/uc?export=view&id=1OcDAp0ZbcBfgXtVLMJAkqkAE9qnb2wX8

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 considered coherent cooperative well oriented 
Cranial nerves - intact
Sensory system- normal
Motor Tone power bulk reflexes are normal in all 4 limbs 
PROVISIONAL DIAGNOSIS : Fever under evaluation with thrombocytopenia and hypotension
 

INVESTIGATIONS- Hemogramhttps://drive.google.com/uc?export=view&id=1rLD1k-x3BQOn_SvYDsrZw78FE5xgtHI8

RBS
https://drive.google.com/uc?export=view&id=1bBuAOJX1_4_2rp8ethoCv2kp1U4tU8EE
BLOOD UREA 
https://drive.google.com/uc?export=view&id=1EZ2ACP3wjjecyAZa2kdi3OIeY5KoPzuh
SERUM ELECTROLYTES:

https://drive.google.com/uc?export=view&id=1CkAxNy4UIR4wrs3gNvWlTyw6dDSW-I-Q
LFT:
https://drive.google.com/uc?export=view&id=1Cf14QqLdqZ9dHeTNBWHU4lHPP_gfqAzy
DENGUE NS1 ANTIGEN :
https://drive.google.com/uc?export=view&id=1_9lPHbp3Uy1lM5mqaDBnYnCiztb1-EJe
WIDAL TEST :
https://drive.google.com/uc?export=view&id=1PNSou-fqZGDQpfe-Ym6k8Nnwu-wh0GBn
SERUM CREATININE:
https://drive.google.com/uc?export=view&id=17sVXcoddkaUz7cdCv1XtTz91Fuy5eleP
ECG:
https://drive.google.com/uc?export=view&id=1jXgaGzu8qO_buCCmWiOg8dA9NLKCVG1h

TREATMENT : 
1.IV NORMAL SALINE 
    Ringers lactate 
2.TAB DOLO 650 mg 
3.Plenty of oral fluids 
Tepid sponging 
4.INJ MONOCEF 1gm 
5.INJ FALCIGO 120mg 

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