A 62 year old male patient with viral pyrexia under evaluation.

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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 a diagnosis and treatment plan



CHEIF COMPLAINTS 

A 62 year old male came to casualty with

C/o fever, since 3 days high grade a/w chills


HOPI

Patient was apparently asymptomatic 3 days back , then he developed fever, high grade ,insidious in  onset a/w chills, relieved on medication 

No H/o Headache.

No H/o cold, cough.

No H/o vomitings , loose stools

PAST HISTORY 

K/c/o DM since 5 years and is on Tab. GLIMI M1 

Not a K/c/o HTN, TB,Asthma,Epilepsy,CAD


PERSONAL HISTORY 

DIET- Mixed

APPETITE- Normal

B&B- Regular

ADDICTIONS: Chronic Alcoholic.


FAMILY HISTORY - Not significant 


GENERAL EXAMINATION 

No PALLOR

NO ICTERUS

NO CYANOSIS 

NO CLUBBING 

NO EDEMA

NO LYMPHADENOPATHY 

Vitals

Temp: 98.8 F

PR: 100 bpm

BP: 100/60 mmhg

RR: 22 cpm

Spo2: 98  % @ RA

GRBS: 400 mg/dl

Systemic examination 

CVS: S1 S2 +, NO MURMURS
   RS: BAE+, NVBS
   P/A: SOFT, NT, BS+
   CNS: INTACT.

INVESTIGATIONS













 
PLAN OF TREATMENT 

IVF NS & RL @ 100 ml/hr
Inj.PAN 40 mg PO/OD
Inj.OPTINEURON 1 amp in 100 ml NS/ IV/OD
Tab.DOLO 650 mg/SOS
Inj.NEOMOL 1gm/IV/SOS
BP & PR Monitoring 4th hourly
Inj. HAI S/C acc to GRBS















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