40 YEAR OLD MALE WITH FEVER AND VOMITINGS

 Kausalya Varma, Intern 

This is 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 patients 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 comment box is welcome.

 I’ve 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. 



40 YEAR OLD MALE WITH FEVER AND VOMITINGS  


CHIEF COMPLAINTS:


A 40 year old male came with the chief complaints of fever since 1 days and vomiting since 1 day. 

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 2 days back then he developed fever with chills and rigor sudden in onset and continuous in nature 
Not relived on medication 

H/o vomiting associated with nausea since yesterday, which had food particals as content, was 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-

No similar complaints in the past 
Not a known case of DM, HTN, asthma, thyroid, epilepsy, CAD

FAMILY HISTORY

Not significant in this case  
 

PERSONAL HISTORY

Diet- Mixed
Appetite- Normal
Bowel and bladder-regular 
Sleep- adequate 
Addictions-consumes alcohol and toddy occasionally 


EXAMINATIONS 


GENERAL EXAMINATION 

Patient is conscious coherent cooperative well oriented to time place and person moderately built and nourished 
Patient was examined in well lit room and consent was taken 
 
Vitals 
Pulse rate- 72bpm
B.P - 110/80
R.R 20/ min
Temp-

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 

Cardiovascular system-

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-




INVESTIGATIONS











 
DIAGNOSIS 

Fever under evaluation with thrombocytopenia and hypotension
 
DIAGNOSIS 
IV fluids (NS,ringer lactate)
                   Inj.neomol 
                   Tab dolo
                   Plenty of oral fluids
                    Tepid sponging 
                    Inj monocef 
                    Inj.Falcigo 

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