38yr old male with Fever, nausea,vomiting, headache

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 This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect6current best evidence based input
This Elog also reflects my patient centered online learning portfolio.
Your valuable inputs on comment box is welcome
 I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever


Under the guidance of 

Dr.Sri Harsha 

Dr. Vinay PGY3

Dr.Pavani PGY1




This is a case of 38 yr old male, driver by occupation has come to the casualty with the chief complaints of 

1)Fever since 4days 

2)Nausea and vomiting since 4 days 

3)Headache since 3 days 

HOPI

The patient is apparently asymptotic 4 days back 

She developed fever which was high grade associated with chills and rigors, retro orbital pain 

Vomitings,immediately after taking food of episodes   which are non bilious, non foul smelling, non blood stained , non projectile contained food particles 

Headache 

There is no history of bleeding gums, hemetemasis, malena or burning micturition


PAST HISTORY 

He is not a known case of diabetes, hypertension, asthma,epilepsy, cad 

PERSONAL HISTORY 

Diet- mixed

APETITE - normal 

Sleep- adequate 

Bowel and bladder movements- regular 

Addictions-

FAMILY HISTORY 

not significant

GENERAL EXAMINATION 




The patient is conscious coherent cooperative well oriented to time place and person 

He is moderately built and nourished 

Pallor-absent 

Icterus - absent 

Cyanosis-absent 

Clubbing -absent 

Edema -absent 

Lymphadenopathy -absent 

VITALS 

Temp-98.6

BP-120/80

Pr-82bpm

Rr-16cpm

Spo2-98

GRBS-102


SYSTEMIC EXAMINATION 

CVS-s1s2+

RS-BAE+

PA-soft and non tender 

CNS- higher motor functions intact 


DIAGNOSIS 

Viral pyrexia with thrombocytopenia 

INVESTIGATIONS 

 AB+ve

RBS 100


Anti hcv non reactive 

Dengue ns1 +ve ;IgM and IgG -ve

Hbsag-ve


30/8/22

5:00pm


9.00pm








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