17 year old boy with complaints of high fever and abdominal pain

22 August  2022

Hi, I'm Shanmukha Pasam, 3rd Sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end.

CHIEF COMPLAINTS:
C/O fever since 5 days and stomach pain and vomitings since 2 days

HISTORY OF PRESENT ILLNESS:
Patient had fever since 4-5 days and chills during night time. He went to a nearby RMP and took medication for fever which subsided on medication.
Patient had stomach pain and vomitings since 2 days for which he went to the hospital. He used to vomit everything he ate. At that hospital he got to know that his platelets level had decreased(thrombocytopenia) due to which he was admitted in our hospital.

Fever subsided
Vomitings subsided
Stomach pain when abdomen is palpated.

HISTORY OF PAST ILLNESS:
Nil

PERSONAL HISTORY:
Loss of appetite
Non-vegetarian
Bowel: regular
Micturition: normal
No known allergies 

ADDICTIONS:
Nil

FAMILY HISTORY:
No significant family history 

PHYSICAL EXAMINATION
General examination:
No pallor
No icterus
No cyanosis
Clubbing of fingers and toes-Absent
Lymphadenopathy-Absent
Edema of feet-Absent

Vitals:
BP: 110/70 mm Hg
Pulse Rate: 81 bpm
Temperature:98.6°F
SpO2: 96%

Systemic Examination:
• CVS
  No thrills
  S1 and S2 heard
  No cardiac murmurs
• Respiratory system
  No dyspnea 
  No wheezing
  Trachea-central
  Vesicular breath sounds
• Abdominal Examination
  Shape of abdomen: Scaphoid
  No scars
  No sinuses
  No visible mass
  No palpable liver
  No palpable spleen
• CNS
  Conscious 
  HMF intact
  Cranial nerves intact
  No focal neurological defects
Investigations:





  

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