50 year old male with viral pyrexia

 Mallannagari.Srilekha roll.no:77 9th semester 

This is online E log book to discuss out patients de-identified health data shared after taking his guardian`s informed consent. Here we discuss our individual patient`s problems through series of inputs from available global online community of experts with an aim to solve patients clinical problems with collective current best evidence based inputs. This E log book also reflects my patient centered online learning portfolio and your valuable inputs on comments box is welcome.

A 50 year old male came to the opd with 

Chief complaints of : fever since 3 days 

Cold and cough since 3 days 

History of presenting illness:

The patient was apparently asymptomatic 3 days back and then he had fever which is of high grade and associated with cills and rigors 

Cough since 3 days which is sudden in onset and productive with mucoid nature. Not associated with shortness of breath.

Cold since 3 days.

No history of chest pain, palpitations.

No history of pedal edema, decreased urine output, abdominal distension.

Past history 

Medical history

Not a known case of hypertension, diabetes mellitus, tuberculosis, Asthama, epilepsy, CVA

No Past surgical history. No history of blood transfusions.

Personal history:

Diet mixed

Appetite normal 

Bowel and bladder regular

No known allergies

No Alcohol Ink take and no smoking.

No significant family history.

General examination:

patient is conscious ,coherent, cooperative and oriented to Time, place , person.

Pallor no

Icterus no

Cyanosis no

Clubbing no 

Lymphadenopathy no 

Edema no 

Vitals

Pulse rate 78bpm, regular , normal volume.

Blood pressure 130/90 mmHg measured  in right arm

Respiratory rate18 cpm

Temperature afebrile

SpO2 98% at room air.

Systemic examination:

CVS:S1 and S2 heart sounds heard.

No murmurs heard

RESPIRATORY SYSTEM

Position of the trachea central

BAE present , vesicular breath sounds heard

ABDOMINAL EXAMINATION

Palpation: liver and spleen not palpable and no palpable masses.

Hernial orifices are free.

No free fluid no bruits 

bowel sounds heard 

CNS EXAMINATION:

Higher mental function intact.

Cranial nerve examination normal

Motor system normal 

Sensory system normal

No meningeal signs

INVESTIGATIONS

TREATMENT:

IVF NS , RL 100ml/hr

Inj.PAN 40mg IV OD

Inj.OPTINEURON1 amp in 100 NS/IV:OD

Tab.DOLO 650mg SOS 

Temperature monitoring