23 years old man came to hospital with fever since 1 week associated with abdominal pain





  Hi, I am Niteesh Gangina (roll no :81)3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

Patient was a symptomatic 1 week back and then developed fever which is low grade not associated with chills,associated with abdominal pain for which he went to hospital.

Chief complaints 

The patient developed fever which is low grade not associated with chills 1 week back associated with abdominal pain

History of present illness

Vomiting and episode on day 2 of fever and constipation for 2 days which is 4 days back and abdominal plain and rashes were seen on his  thigh


History of past illness

Polio since birth


Personal history 

Occupation works in festival shop 

Diet:mixed

Appetite:normal

Sleep:normal

No known allergies

FAMILY HISTORY 

 Diabetes - No

Hypertension -No

Heart disease - No

Stroke - No 

Concern - No

Tuberculosis-no

Asthma - No

General examination 

No pallor 

No icterus 

No cyanosis 

No clubbing of fingers

No lymphadenopathy 

No pedal odema 




SYSTEMATIC EXAMINATION:

B. CARDIO VASCULAR SYSTEM

1. Thrills No 

2. Cardiac Sounds

3. Cardiac murmurs No 

C. RESPIRATORY SYSTEM

1. Dyspnoea - No

2. Wheeze - No 

3. Position of Trachea - Central

4. Breath Sounds - Vesicular

5. Adventilious Sounds - No

D. ABDOMEN

1. Shape of abdomen - Scaphoid 

2. Tenderness - No

3. Palpable mass - No 

4. Hernial Orifices Normal 

5. Free Fluid No 

6. Bruits No 

7. Liver - Not palpable

8. Spleen - Not palpable 

9. Bowel sounds -Yes


Central nervous system 

1.level of conscious conscious and covert

2.speech normal

3.sign of menningeal irritation

Neck stiffness no

Kerning sign no

Cerebral signs

Finger nose test in coordination 

Knee heel test in coordination 

Investigation 




Treatment
28/08/22
Doxycycline 
Pantop
Dolo
Citrizine
Atorvas
29/08/22
Doxycycline 
Pantop
Dolo
Citrizine 
Atorvas
Opineuron

Comments

Post a Comment

Popular posts from this blog

A 60year old man came to hospital with complaints of tremors in right hand

Image
  A 60year old man came to hospital with complaints of tremors in right hand   Hi I am, Niteesh Gangina(roll no:81), 5th sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio. A 60year old male agricultural worker by occupation came to hospital with complaints of tremors in right hand Chief complaints Patient complaints of tremors in right forearm and hand History of presenting illness Patient was apparently asymptomatic 2years back He then developed shivering of right hand and arm which was   Insidious on onset and gradually progressive Initally shivering was localised to fingers only, later radiated to Palm.   numbness present Decreased power in right hand inability to hold things,unable to eat food, unable to work.   pain in right thigh   Shivering of right hand aggravated due to stress, anxiety fear, present for sometime during sleep.
Read more

A 60year old male agricultural worker by occupation resident of gudivada (Nalgonda)came to hospital with complaints of swelling on upper and lower limbs ,face since 1 week

Image
  Hi I am, Niteesh Gangina(roll no:81), 5 th sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio. A 60year old male agricultural worker by occupation resident of gudivada (Nalgonda)came to hospital with complaints of swelling on upper and lower limbs ,face since 1 week Chief complaints Patient complaints of swelling in limbs and face since 1 week History of presenting illness Patient was apparently asymptomatic 1 week back  He then developed swelling of body -upper limbs,lower limbs and face Pitting type, insidious onset and gradually progressive Complaint of chest pain,palpitation and decreased urine output SOB Ulcer over sacral region History of past illness Not a known case of  Diabetes  Hypertension Epilepsy Asthma Tuberculosis No history of trauma in the past Personal history Sleep:adequate  Diet: mixed Bowel and bladder movements:
Read more

A 66 years old man came to hospital with severe itching and pustules since 3 days

Image
  Hi, I am Niteesh Gangina (roll no :81)3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio. A 66 yr old male patient farmer by occupation with itching all over his body since 5 years.pustules since 3 days. Chief complaints  The patient came to the hospital 8days back with chief complaints of excessive itching with blisters all over his body. History of present illness Patient is suffering from itching from past 5 years and took black magic treatment for painful lesions on both legs,chest and both arms History of past illness In the past due to lack of micturation the patient had undergone an surgery. The patient  is also diagnosed with hypertension 2yrs back and diabetes 5 years backs. The patient is not a known case of asthma and tuberculosis.  Personal history  Diet:mixed Appetite:normal Sleep:normal No known allergies  General examination  No pallor  No ict
Read more