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A 63yr old pt with fever n sob

 Immani Aasritha

3rd semester,2k19

Aug,08,2021

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.
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.

CASE SCENARIO:
A 63 yr old patient came to casuality with chief complaints of fever intermittent in nature associated with chills since one week and sob since 3 days.

HISTORY OF PRESENT ILLNESS:
Patient was asymptomatic 15 days back when he developed fever and generalised weakness, patient experienced sob since 3 days 
Outside HRCT - 11/25

HISTORY OF PAST ILLNESS:
N/K/C/O - DM, HTN

TREATMENT HISTORY:
No usage of drug as of now 

PERSONAL HISTORY:
Married
Occupation - farmer
Appetite - Normal 
Non vegetarian
Bowls - Regular
Micturition - normal 
No  known allergies
Occasional alcohol

FAMILY HISTORY:
NAD

GENERAL EXAMINATION:
No pallor
No icterus
No cyanosis
No clubbing
No klionchelia
No Lymphdenopathy
No edema 
No malnutrition
No dehydration
Temperature - Afribrile C/F
Pulse rate - 129 bpm
R.R - 22cpm
B. P- 90/60mm/hg
Spo2- 80%
GRBS -high 

SYSTEMATIC EXAMINATION:
CVS-
No Thrills
Cardiac Sounds - S1, S2 +
No cardiac murmurs
RESPIRATORY-
Bae+
Dyspnoea- yes
Position of trachea - central
Adventitious sounds - crepts
ABDOMEN-
Shape - Scaphoid
No tenderness, palpable mass, free fluid, bruits 
Hernial orifice - normal
Liver - not palpable
Spleen - not palpable
Bowl sounds - yess
Genitals - normal 
CNS-
Level of consciousness - drowsy
Speech - normal 
Signs of meningial irritation - no 
Cranial nerves - intact 
No motor / sensory deficit
CEREBRAL SIGNS -
Finger nose in-cordination - no 
Heel knee in-coordination - no 
Reason for lack of coordination?? 
Gait - normal

INVESTIGATIONS :
      


PROVISIONAL DIAGNOSIS: 
Covid - 19 
What does cerebral signs indicate?? 

TREATMENT:

1.Neb c budecot
2.Inj HAI 60 IV/STAT
3.IVF NS 20ml/kg/hr
4.INJ PANTOP 40mg

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