A 19yr Old male came with fever, pain in abdomen , low back ache and generalised weakness

 This is a online e-log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitt.
 
Chief complaints:
19yr Old male came with complaints of fever , pain abdomen , low back ache and generalised weakness since 3 days

HOPI:
Patient was apparently asymptomatic 3 days back then he developed fever which is insidious in onset , gradually progressive not associated with chills and rigors 

C/O pain abdomen insidious in onset , diffuse type not associated with nausea /vomiting

C/O low back ache ( insidious , gradually progressive ) not associated with tingling /numbness

C/O Generalised weakness since 3 days

Not a k/c/o DM/HTN/TB/EPILEPSY


Personal history:

Diet:mixed
Appetite:normal
Bowel and bladder movements:normal
Appetite : decreased
Sleep : adequate 
No additions

On examination:
Pt is c/c/c 

Temp - 98.6F
Bp - supine - 110/80mm hg
        Standing -  120/90mm hg
PR - supine - 108bpm
         Standing - 108bpm
RR - 20cpm
Spo2 - 97% at RA
CVS - S1S2 +NO MURMURS 
RS - NVBS +
PA-soft non tender BOWEL SOUNDS HEARD 
CNS-NFD
Inspection-
Shape of abdomen is normal
Umbilicus- central and inverted
Hernial orifice is normal
Palpation-
Hepatomegaly and spleenomegaly are present
Tenderness is present
Percussion-

Resonant

Ascultation-

Bowel sounds+

Investigation:
NSA1 antigen- positive 

Recurrent temperature changes
D/D:

Dengue fever or malaria?


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