A 17 year old male patient complaints of fever and stomach pain
A 17 year old male patient complaints of fever and stomach pain
. No clubbing of fingers
23 August 2022
E LOG GENERAL MEDICINE
Hi, I am Naalla Gayathri , 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.
CHIEF COMPLAINTS:
Patient complaints of fever and chills since 4-5 days and stomach pain.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 4 days back then he developed fever associated with chills, intermittent with evening rise of temperature which is relieved on medication.
He took medication including injections given by an RMP doctor. Next he diagnosed with dengue in a nearby hospital.
Sunday he had vomitings which is non bilious type.
He vomited the food he consumed.
Next day morning he complaints of black colour stool and brownish red urine and also tightness of abdomen.
He had blood transfusion of 1 unit on Sunday.
PAST HISTORY:
No history of hypertension,diabetes,asthma, tuberculosis, thyroid , epilepsy.
PRESENT HISTORY:
Diet:mixed
Appetite: normal
Sleep: adequate (sleeps more)
Bowel: normal(black stool on Monday)
Bladder: normal(brown colour from Monday)
Addictions:None
FAMILY HISTORY:
Father have diabetes.
ALLERGIEC HISTORY:
No known allergies.
GENERAL EXAMINATION:
Patient was conscious, coherent and cooperative.
Pallor - absent.
No edema is noticed.
VITAL SIGNS:
PR: 72 bpm
RR: 20 cycles per minute
BP: 110/60
Temperature:98.2 F
PO2: 98%
INVESTIGATIONS:
Fever chart
Ultra sound
2D echo
ECG
