Case history-3

 

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 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

A 40 year old patient presented to opd with the chief complaint of fever , stomach pain , headache 

History of present illness: Patient was apparently normal 20 days back and then he developed fever and stomach pain in the left iliac fossa region associated with back pain also.patient also complaints of diffuse type of headache . The fever raises to peak during night causing sleeplessness. There is also blood in stools.

History of past illness: an year back patient suffered from stomach pain , indigestion, and fever.upon consulting the doctor it was diagnosed the presence of an ulcer in the stomach for which he used medication for a week and then stoped the medication as the symptoms are subsided. he is not a known case of diabetes or hypertension.

Personal history: patient follows a mixed diet (2 meals per day).there is loss of appetite.regular bladder and bowel movements but blood was detected in stools.payient has a habit of smoking 10 yrs back .he also have a habit of alcohol (palm wine) consumption-1 bottle per day.no habit of tobacco.

Family history : no similar complaints in any member of the family.

Drug history: no allergy to any of the known drugs

General examination: patient is concious, coherent and cooperative.he moderately built and nourished.no pallor no cyanosis no icterus no lymphadenopathy no pedal oedema

Vitals: temperature:98.4c

            Blood pressure:130/90

            Pulse rate:89 bpm

            Respiratory rate:20 cpm

            Spo2: 97%

            Grbs:140mg/dl

Systemic examination: 

CVS: Chest wall is bilaterally symmetric.no precordial bulge,no murmurs,no thrills

JVP: normal s1 s2 heard

Respiratory system: no dyspnoea, no wheeze

Position of trachea-central, no adventious sounds heard.

Abdomen: tenderness in the left iliac fossa region .

CNS: patient is normal and concious .reflexs are normal

Provisional diagnosis: viral pyrexia