16 yr old male with c/o fever

16 year old male came to casualty with c/o fever

This is an 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.
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
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. 

A 16 year old Male came to casualty with 
C/O fever since 4 days
vomitings 6-7 episodes per day since 4 days, bilious, food as particles
C/O Generalised weakness, bilateral leg pain since 4 days
C/O loose stools 4-5 episodes per day,liquid in consistency since 3 days
Decreased urine output since 3 days
Epigastric pain since morning

Pt was apparently asymptomatic 4days back then on 17/10/22 night after consuming alcohol he developed fever, high grade, intermittent not associated with chills and rigor  Continued for 4 days rel?
He had 7-8 episodes of vomitings since 4 days which is bilious, projectile type
He has generalised weakness with bilateral leg pain since 4 days
He has 4-5 episodes of loose stools(liquid consistency) per day for 3 days
 Decreased urine output since 3 days
Epigastric pain since morning,dull aching type,not radiating type
No H/O burning micturition,headache
Addictions: alcohol since 6 yrs(occationally-2,3 times per week
cannabis since 6yrs(1-2smokes per day)
tobacco smoking since 6yrs(daily 10 per day)
K/C/O epilepsy since 4 yrs (not on regular since 2yrs medications)
N/K/C/O HTN,DM,TB,asthma,Thyroid,CVA,CAD
Occupation:fast food master
Sleep-inadequate
Mixed diet
General examination:
No pallor
No icterus  
No cyanosis 
No clubbing 
No generalized oedema

Vitals:  
On admission 
Pt is Conscious, coherent, cooperative 
Temp: 99.1F
PR: 98BPM
RR: 16Cycles per min 
BP: 80/60 mmhg 
Spo2: 99
GRBS:118mg/dl

      Systemic examination:

CVS examination:
S1S2+

Respiratory system examination :
Bilateral Airway E +

Per abdomen examination:
Soft, tender+ right and left hypochondrium and epigastrium, bowel sounds+

CNS:N

Diagnosis:
Pyrexia under evaluation with thrombocytopenia
Acute kidney injury(?acute glomerulonephritis)


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