20year old with fever and vomitings

This is an 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.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

 

THIS IS A CASE OF a 20 year old young male resident of miryalguda .

 Chief complaints 

fever since one week

vomitings since one week. 

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic one week back, he woke up like his normal day ,got freshened up , didn't have breakfast and went outside with his friends ,then he had and episode of vomiting( watery associated with nausea, non projectile, no retching ), then his friends dropped him back home, he then had 2 episodes of vomiting which were watery associated with blood clots( 2 clots per episode which were red in color about 1 to 2 cm) 

Then he went to a local hospital where he was given a tablet ( ?zofer) and was advised to get endoscopy done. 

He also had fever which was high grade, continuous,not associated with diurnal variations, not associated with chills and rigors and rash.

He has history of cough, which was non productive, followed by vomiting.

(He has history of consumption of outside food almost 5 times in the past week

,there are no similar complaints in the friends who consumed the same food.)

The next day( DAY 2)

He went to private hsptl where endoscopy was done

Reports showed mucosal erosions 

His fever didn't subside .

The next day (DAY 3)

He got admitted in the same hospital and was managed conservatively.

 He had no episodes of vomitings but had continuous fever, high grade.

 He was in the hospital for 3 days where he had episodes of fever in between, was managed on medications.

Day 6

He had 3 episodes of vomitings watery, non projectile , not associated with retching 

The doctor informed that the condition is severe can't be managed in their hospital and referred to higher centre .

He was brought to our hospital on day 6 afternoon.

 I took the case on DAY 7 

he had 8 episodes of vomiting since 3:30 am which were non projectile , watery ,non bilious immediately after consumption of water or food, without any retching.

He still has fever spikes.

He has complaints of headache and body pains .

No history of burning micturition.

No history of productive cough , breathlessness.

No history of neck stiffness.

No history of pain abdomen, loose stools.

No history of weight loss.

PAST HISTORY

No similar complaints in the past.

No history of diabetes, hypertension,asthma, tuberculosis, epilepsy.

PERSONAL HISTORY :

he has been staying at home past one year after completion of his training in ITI . 

His daily routine :

he wakes up at 8:00 am in the morning, gets fresh up and takes breakfast occassionally and goes out with friends

then comes home and skips his lunch most of the time and sleeps and then goes out with friends in the evening and comes home at 10:00pm and has his dinner by 11:00pm 

He consumes tea or coffee 10 to 20 times a day 

No history of alcohol consumption or smoking.

FAMILY HISTORY:

No significant history in the family.

GENERAL EXAMINATION:

patient is conscious, coherent and cooperative , well oriented with time, place and person

He is moderately built and nourished

He has no pallor 

Icterus 

Bulbar conjunctiva clear 

No cyanosis 

No clubbing 

No generalised lymphadenopathy

No pedal edema.

A single palpable lymph node is present in the right upper cervical region, which is soft in consistency, about 1.5 cm size and slightly mobile.

He has two tattoos( becomes significant if serology turns out positive)

Vitals :

Temperature: 

PR :101 bpm 

Bp : 110/90 mm Hg

RR: 18 cpm

SYSTEMIC EXAMINATION:

ABDOMINAL EXAMINATION

INSPECTION

- Shape - Scaphoid, with no distention.

- Umbilicus  - central in position, normal 

- Equal symmetrical movements in all the quadrants with respiration.

- No visible pulsation,peristalsis, dilated veins and localized swellings.

PALPATION

- Local rise of temperature present.

NO TENDERNESS 

 - Mild enlargement of liver,

 regular smooth surface  , rounded

 edges , non tender.

- SPLEEN 

palpable just below the costal margin,

 smooth , rounded margins, non tender.

PERCUSSION

- Hepatomegaly :  liver span of 14 cms with

 3 cms extending below the costal margin

- Fluid thrill and shifting dullness absent 

 AUSCULTATION

- Bowel sounds not heard.

-No bruit or venous hum.

NO LOCAL LYMPHADENOPATHY.

CNS 

Higher mental functions intact.

No signs of meningeal irritation.

Normal sensory examination

Normal motor examination.

Cerebellar signs are absent.

CVS :

S1 S2 heard, no murmurs.

RESPIRATORY SYSTEM

Bilateral air entry present, Normal vesicular breath sounds on both sides.

PROVISIONAL DIAGNOSIS 

Fever under evaluation 

Gastritis ( due to associated risk factors)

My differentials for fever

? Viral Hepatitis 

? Typhoid

? Malaria

INVESTIGATIONS

CBP

CUE

LFT

Serum electrolytes 

Blood urea

Serum creatinine 

ENDOSCOPY REPORT ( OUTSIDE)

Ultrasonography 

Chest X ray

Liver function test on day 8

Hcv serology

at our hospital :

First sample was positive, so repeat sample was sent and it came out negative

Another sample was again positive

So planned for HCV Rna 

SAMPLES ARE SENT FOR 

WIDAL TEST  

BLOOD CULTURE

URINE CULTURE 

Repeat sample for  serology 

TREATMENT:

NIL BY MOUTH

MONITOR VITALS

INJ PAN

INTRAVENOUS FLUIDS :

RL 

NS

INJ NEOMOL 1gm SOS (if temperature is above 101 degree)

Tab DOLO 650 MG PO TID

Data on association of tea and gastric acid release: 

(to explain his pangastritis )

https://pubmed.ncbi.nlm.nih.gov/6546540/

Quoting the main lines :

Gastric acid response to a 200-ml cup of tea was measured by in situ titration in 36 patients with duodenal ulcer (DU) and 56 without duodenal ulcer (controls). Tea resulted in an acid secretory response which was almost equal to that after a maximal dose (0.04 mg/kg) of histamine. The effect of tea was mainly due to its local chemical action on gastric mucosa.

My questions regarding this case:

Do dietary habits alone show association with gastritis? Or should H pylori be ruled out? 

How common is acute gastritis ( like in this case) associated with H pylori?

How can we be sure that gastritis and the fever, positive examination findings are separate entities?

Is there a need to rule out viral gastritis? Does a CMV or HSV viral infection explain all his features? 

What is the sensitivity and specificity of Rapid diagnostic tests of HCV?

Are there any case studies of hepatitis C and acute gastritis?

I have found cases of chronic autoimmune gastritis, in hepatitis C patients, but doesn't fit in this case.