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


28 August 2022

E LOG GENERAL MEDICINE 

Hi, I am Shanmukha Pasam, 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

Source: My classmate Nalla Gayatri

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