60 Yr Old Male with Fever.

 

E LOG GENERAL MEDICINE








Hi, I am Rishitha, 5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING!



Chief complaints:


Fever since 1 day 
Cough since 1 day 
Vomiting since today morning 

HOPI 

pt was apparently asymptomatic then he developed fever which is of high grade intermittent a/w chills and rigor, vomitings

(non projectile non bilious watery filled with food particles

No c/o pain abdomen cold loose stools burning Micturition



Past history : 

N/k/c/o HTN , DM , thyroid epilepsy asthma CAD CVD

H/o pneumonia? 3 months back 



General examination 

Pt is conscious coherent cooperative 

No pallor icterus cyanosis clubbing edema lymadenopathy 


VITALS 


BP: 130/80

PR: 86/min

RR: 18/min

Temp: 99F

Spo2 : 99%

GRBS : 98mg%


Systemic examination :

   

Cvs : s1s2 heard no murmurs 

PA : soft and non tender, no organomegaly 

CNS : No focal neurological deficit

RS : BAE+ b/l crepts present in Rt IAA


Investigations: 









PROVISIONAL DIAGNOSIS: 

              Viral pyrexia with thrombocytopenia 


TREATMENT: 



IV fluids NS or RL @ 100 ml /hr

Inj NEOMOL 1gm I/SOS (if temp > 101F)

Inj ZOFER 4 mg IV/SOS

Tab PCM 650 mg PO/QID

Monitor vitals 4 hrly





















 

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