80 yr old with fever and cough.
This is online E-blog, to discuss our patient de-identified health data shared after taking her 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 the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
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 a diagnosis and treatment plan.
Our 80yr old male patient came to the opd with chief complaints of
1.fever since 7 days.
2.Dry cough since 5 days.
HOPI:-
Patient was Apparently asymptomatic 7 days back then he developed fever which is on &Off ,also has dry cough since 5 days
No headache,No burning micturition,No nausea,No loose Stools.
PAST HISTORY:-
Not a known case of HTN,DM,TB,EPILEPSY.
EXAMINATION:-
Patient was conscious, coherent, cooperative,well oriented to time ,place and person .
No- pallor ,Icterus,cyanosis, clubbing, lymphadenopathy.
Temp- Afebrile (98.5f)
Bp- 100/60 mm hg
PR- 90 BPM
RR- 18 cpm
Spo2-98%
CVS- S1,S2+
RESP-BAE +
PER ABDOMEN-soft &non tender.
CNS- NAD.
PROVISIONAL DIAGNOSIS:
VIRAL PYREXIA WITH THROMBOCYTOPENIA.
INVESTIGATION:-
ON 19-08-2022
TREATMENT:-
IVF. 2×NS,2×RL@ 75ml/hr.
INJ.NEOMOL 1gm IV SOS
TAB .PCM 650 mg po BD
TAB.ZOFER 4 mg po sos
SYP.ASCORIL -D 15 ml Po BD.
