A 70 year old female patient with fever body pains and vomitings



This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient 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.


A 70 year old female came to OPD with the chief complaint of fever vomitings and body pains since two weeks 

Patient was apparently asymptomatic two weeks back and she referred to a local clinic and after a week was shifted to our hospital. Patient had fever which was intermittent,continous and decreased with medication and also burning micturition and tingling and burning sensation of hands and feet 

Vomitings on food consumption around four times a day and non Bilous non projectile and food particles as content 

Loose stools,breathlessness and dryness of tongue and pain in inner buccal mucosa and swelling and pain during swallowing.

Daily routine - She is a house wife and used to wake up around 6:30am and goes for a walk for an hour And consume food that included cereals like bajra jowar. She used to have lunch around 12:30,consumed chapathi and rice and did daily routine household activities and then dinner at 8pm and used to have cereals. 


Past history:-

She was taken previously to other clinic for the same cause and then she was investigated there to find out that the platelet count was 22,000, hb was 11000 and and wbc 4,600

Diagnosed to have viral pyrexia with thrombocytopenia with no bleeding manifestations.

Known case of diabetes Mellitus and hypertension since 10 years.Not a k/c/o asthma,epilepsy,TB.


Personal history:-

Diet- mixed 

Apetite- normal 

Sleep- inadequate 

Bowel movements- normal 

Addictions- none 


General examination:-

Pt is conscious, coherent, cooperative,well oriented to time ,place and person. 

No sign of clubbing, cyanosis



Vitals:-

Temp- 99 F 


Bp-120/80mm hg


Pr- 89bpm


Rr-16cpm


Spo2- 98% on RA


GRBS- 234 mg%



Systemic examination:-


RS- bae+ ,normal vesicular breath sounds 


Cvs-S1 S2 +, no murmurs heard



























Treatment:-
IVF NS
Inj neomol
Tab dolo
Tab glimiperide 
Tab metformin 






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