A 28 year old male presented to OPD with FEVER and Epigastric pain. case 1.

Hello! This is Ananya Aleti, a 3rd semester student of Kamineni institute of medical Sciences , Narketpalli here to give you insight into the details of certain cases I've come across. The data gathered and presented in this blog is taken with consent from the patient or their Guardians. This blog represents my understanding of the following medical conditions and assessments made.

Chief complaints

A 28 year old gentleman from Nalgonda came to the OPD with chief complaints of pain in the epigastrium along with abdominal tightness and loss of appetite.

History of present illness

The patient was apparently asymptomatic 6 days ago, until he developed a fever of 103'F at night with chills and rigor . The patient then went to a local medical practitioner and was given a medication for fever and it subsided.

The next day patient developed a fever again , an evening rise of temperature along with chills. It subsided with medication which was symptomatic.

Then the patient developed pain in the epigastric region of abdomen. The Pain was not subsiding even after taking antacids. He had tingling sensations on all four limbs since evening and it was not associated with numbness, postural hypotension , giddiness, pain or weakness.

No hematemesis or black tary stools seen.

History of Past illness

No history of Diabetes mellitus/ hypertension /bleeding disorders.

He had right limb fracture 7 years ago and a nail placement was done.

Personal History 

The Patient is farmer by occupation.

He is Single.

Regular Bowel movement.

Abnormal Micturition.

A teetotaller 

Family History

No significant family history .

Physical examination

a. General Examination

Well built

Well nourished

No pallor

No icterus

No clubbing of fingers

No lymphadenopathy

Mild dehydration 

b. Vitals

Temperature: 99'F

Pulse:

Respiratory Rate:

BP :120/80 mm of hg in supine position

        110/80mm of hg in standing position

Investigations

Hemogram - 01/09/2022

  

Serum CREATININE 

Complete Urine Examination

Ultrasound

Impressions : - Moderate Ascites

                      - mild splenomegaly

                      - edema of wall of Gall bladder

TPR Chart :

Treatment/ medication 

IV Fluids- NS and RL given 100 ml per hour for 2 days.

Strict Temperature Monitoring.

Hemogram - 05/09/2022