A 60 year old male patient came to casualty with c/o high grade fever since 5 days
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 available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs
A 60 year old male patient came to casualty with
c/o:
High grade fever since 5 days,
Dry cough since 6 days,
SOB on exertion since 4 days.
constipation since 4 days.
burning micturation since 10 days.
HOPI:
Patient was apparently asymptomatic 10 days back, then he had burning micturation,and high grade fever associated with chills and rigor,he had constipation since 5 days. He also had nausea and dry cough.
PAST HISTORY:
Patient is a k/c/o DM since 30yrs and was on medication.Also K/C/O HTN since 30 years.
Not/k/c/o TB,Asthma,Epilepsy.
PERSONAL HISTORY
DIET- MIXED
APPETITE- Normal
SLEEP- Adequate
B&B- Decreased
ADDICTIONS- Consumes alcohol occasionally.
Family History:
No relevant history in family
Treatment History:
GENERAL EXAMINATION:
patient is concious/coherent/cooperative, moderately built and nourished.
No pallor
No icterus
No clubbing
No edema
No lymphadenopathy.
Vitals: Temp- 101 F
PR- 80 BPM
RR- 19 CPM
BP- 120/70 mm Hg
SpO2- 98%@ RA
GRBS- 387 mg/dl
Systemic examination:
CVS: S1 S2 + ,NO MURMURS
RS: BAE+, NVBS
CNS: INTACT
P/A: SOFT, DISTENDED, GUARDING + ,BS SLUGGISH.
Investigations:
ECG:
Ultrasound:
Comments
Post a Comment