A 38 years old man with fever, nausea, headache, vomitings

38 year old man complaints of fever, headache,nausea, vomitings

28 August 2022

E LOG GENERAL MEDICINE 

Hi, I am P.Karthi vijayani, 3rd Sem Medical Student.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 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 a diagnosis and treatment plan. 

DATE OF ADMISSION:25th August 2022

CHIEF COMPLAINTS:

Patient complaints of fever since 1 week, headache since 4 days, nausea and vomitings since 2 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 5 years back,then he was in stress as his brother has serious health issues following which he developed low grade fever and neck pain,then he diagnosed  with hypertension.

Since 1 week patient had fever associated with chills, headache and neckpains.

 PAST HISTORY:

Known case of hypertension since 5 years.

No history of diabetes, asthma, tuberculosis, epilepsy, thyroid.

PRESENT HISTORY:

Diet:mixed

Appetite: normal(decreased since fever)

Sleep: adequate

Bowel: regular 

Bladder: regular

Addictions: Alcohol (occassionally)

FAMILY HISTORY:

Mother had asthma.

ALLERGIEC HISTORY:

No known allergies.

GENERAL EXAMINATION:

Patient was conscious, coherent and cooperative.

Pallor - absent.

No edema is noticed.

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills 

No murmur 

Respiratory system:

Dyspnea is absent.

Wheeze: no

Abdomen:

Shape : scaphoid

No tenderness

No palpable mass

CNS:

Conscious

Normal speech

Gait - normal

VITALS:

PR: 107 bpm

RR: 36 cycles per minute

BP: 130/90

Temperature:98.3 F

PO2: 96%

INVESTIGATIONS:

Fever chart

  Ultrasound 

    

 2D echo

  ECG