Fever abdominal pain

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 This is 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 patients 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 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 diagnosis and treatment plan "




53 yr old male came to OPD with 
Chief complaints of :

- fever since 4 days 
- abdominal discomfort , bloating and loss of appetite since 4 days 
- burning micturition since 4 days 
- no passage of stools since 4 days 



HISTORY OF PRESENT ILLNESS :

- Patient was apparently asymptomatic 4 days back , he then developed fever , high grade , intermittent in nature , associated with chills and rigors , headache ,no diurnal variation ,  relieved by medication
- patient complains of burning micturition since 4 days .
- H/O loss of appetite since 4 days .
- the patient complains of abdominal discomfort and bloating after having food
- H/O unable to pass stools since 4 days  
- H/O SOB + 
 - No H/O vomiting , cough , cold  , pedal oedema 

PAST HISTORY :

K/C/O DM 2 since 10 yrs , on regular medication ( Metformin 500 mg + Glimiperide 1 mg ) 

 Surgical history :-
- K/C/O CAD - PTCA done 4 yrs back , 1 stent placed 
- patient underwent appendicectomy in in 2015
- hydrocele surgery ( left jaboulay's procedure ) done in 2017 
- lumbar spine fixation surgery done in 2016 and rods placed

- Not a k /c/ o  HTN , Thyroid , TB , Asthma  Epilepsy , CVA .

Family history : not significant .

PERSONAL HISTORY : 

Diet - mixed 
Appetite - reduced since 4 days 
Bowel movements - constipation since 4 days , bladder - regular 
Sleep - adequate 
Addictions : consumes alcohol regularly since 20 yrs , 90 ml / day 


GENERAL EXAMINATION :


- Patient was examined after taking his consent 
- Patient is conscious , coherent , cooperative , well oriented to time , place and person .He is moderately built and nourished 
- No signs of pallor , icterus , cyanosis , clubbing , oedema , lymphadenopathy .



Temperature : 99.6 F 
BP : 120/80 mm HG 
Pulse rate : 78 / min 
Resp.rate : 16 cpm
GRBS : 167 mg/dl
Spo2 : 98 percent 

Systemic Examination:

CVS- S1 S2 heard,no murmurs present.

RS - bilateral Air entry present
Normal vesicular breath sounds heard

Per Abdomen : soft , tenderness + in epigastrium and right hypochondrium  , bowel sounds + , no signs of organomegaly 


CNS :higher mental functions : normal 
Reflexes : 
MOTOR-: normal tone and power 
reflexes:
             RT           L  T

Biceps ++           ++
Triceps ++          ++
Supinator ++       ++
Knee ++              ++
Ankle ++             ++

2 D echo 

USG Abdomen : 


I/v/O right  renal calculus , patient advised to take plenty of oral fluids and syp . Alkastone 15 ml / bd 

Provisional diagnosis:

Viral pyrexia with thrombocytopenia with HFPEF with RHF


tab PCM 650 mg SOS 
 inj h. Actrapid insulin sc/ tid 
Tab pryoboi 75 mg PO / HS 
Tab ECOSPRIN AV 75/10 HS 
 High fibre diet 
Oral fluids upto 1.5 lit / day with ORS sachets in 1 litre water 
 GRBS monitoring 7 pint profile 
Vital monitoring 4 th hrly




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