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

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