52 year old male with fever,tightness of abdomen and decreased appetite

52 Year old male with fever and tightness of abdomen 

M.sandhya 
1701006117
june8th,2022

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

52 year old male resident of nalgonda  farmer by occupation and came to opd with the 

CHIEF COMPLAINTS;
fever since 4 days
tightness of abdomen since 3 days
decreased appetite since 2 days

HISTORY OF PRESENT ILLNESS

patient was apparently asymptomatic 4 days back then he had fever which is insidious in onset low grade continuous fever gradual in progression not associated with chills and rigors no aggravating factors relieved with medications and he had tightness of abdomen which is sudden in onset and non progressive  associated with breathlessness which is of grade 4, and pain which is squeezing type and non radiating not associated with pedal oedema vomiting diarrhoea 
he also had decreased appetite 
no h/o melaena,diarrhoea hematemesis,nausea,loss of weight, orthopnea

HISTORY OF PAST ILLNESS

no similar complaints in the past 
not a k/c/o DM,HTN,ASTHMA,THYROID 
CVA/CVD
NO significant surgical history 
no h/o blood transfusion 

FAMILY HISTORY
insignificant 

PERSONAL HISTORY 
Diet;mixed
appetite; decreased 
sleep; adequate 
bowel and bladde; regular 
addictions; toddy (occasionally)
no drug allergy 

GENERAL EXAMINATION 
Patient is conscious, coherent,cooperative.
Well oriented to time place & person 
Moderate built and moderately nourished
no pallor,icterus,cyanosis,clubbing, lymphadenopathy

VITALS
pulse rate; 82 bpm 
respiratory rate; 18 cpm 
blood pressure; 120/80
temperature: afebrile 
spo2; 99
GRBS;106
SYSTEMIC EXAMINATION :

CVS:
Inspection:
Chest wall is bilaterally symmetrical.
No precordial bulge
No visible pulsations, engorged veins, scars, sinuses

palpation:
JVP: normal
Apex beat: felt in the left 5th intercostal space in the mid clavicular line.

Auscultation:
S1, S2 heard , No murmurs

RESPIRATORY SYSTEM:
Position of trachea: central
Bilateral air entry +
Normal vesicular breath sounds - heard
No added sounds.

PER ABDOMEN:
Abdomen is soft and  tenderness present in the epigastric region .
mild spleenomegaly seen
Bowel sounds heard.
No palpable mass or free fluid 

CNS :
Patient is Conscious 
Speech: normal
No signs of Meningeal irritation
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact
PROVISIONAL DIAGNOSIS;viral pyrexia with throbocytopenia and with mild ascites

CLINICAL IMAGES;

INVESTIGATIONS 
haemoram;
Blood urea;
Serum electrolytes;

Serum creatinine;
rapid test
Blood group 

ECG

ULTRASOUND 
TREATMENT 
I.v fluids -NS,RL 100 ml /hour
inj.pan 40mg I.v/OD
inj .optineuron 1 amp
inj.zofer 4mg I.V




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