General medicine case:

A 42 yrs old male with fever and vomitings. 
8 june 2023
Hi iam Likitha 3rd semester student. This is an online elog book to discuss our patients health data after taking his consent, this also reflect my patient centered online learning portfolio. 
Case discussion:
Date of admission:7 june 2023
A 42 yrs old male resident of chennaram came to medicine OPD with
Chief complaints of:
•Fever since 3 days
• vomiting on 6 june 2023 at 1pm
History of present illness:
Patient was apparently asymptomatic 3 days back then he developed fever which is insidious, gradually progressive. Fever is associated with chills. He complained decreased urine output since 5 days. 
Vomiting is non bilious, non projectile, non blood stained, contains food. 
No H/O:loose stools, abdominal pain. 
History of past illness:
In feb 2023 patient developed abdominal tightness & chest discomfort he went to nearby hospital where he was diagnosed has antral gastritis. 
1 month back he was diagnosed has type 2 diabetes. 
1 month back patient presented with abdominal distension, pedal oedema & lower back ache . MRI of spine was taken, reports showed mild canal stenosis at L4-L5 and  moderate  canal stenosis at L3- L4. 
K/C/O:HTN ( since 4 yrs), DM( since 1 month) 
N/K/C/O:TB, Asthma, Epilepsy, CAD, CVA. 
No surgeries and blood transfusion. 
Drug History:
STAMLO BETA 0.5 mg for HTN. 
Inj HAI 8 U in the morning and 4U in the evening s/c ( since 1 month) 
Personal History:
Married
Appetite: normal
Diet: mixed
Bowel :Regular
Micturition:Abnormal (pain) 
No allergies
Addictions: Tobacco snuff
Family History: No significant family history. 
Physical Examination:
General examination:
Patient was conscious, coherent and cooperative. 
Pallor: present
Icterus: absent
Cyanosis: absent
 No Clubbing of fingers
No lymphadenopathy
No oedema of feet
Vitals:
Temperature: febrile
Pulse rate:90
RR:24
BP:110/70 mmHg
Systemic examination:
CVS:S1&S2 heard
Abdomen: scaphoid, Soft & no tenderness
Respiratory system: central trachea
                                    No dyspnea
CNS:oriented to time, place and person
          Speech:normal
Investigations:



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