80 year old male patient with fever and cough
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LFT
RFT
CBP
BLOOD GROUPING AND RH TYPING
20/08/2022
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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.
A 80yr old male patient came to the opd on friday with chief complaints of
1.fever since 8 days.
2.Dry cough since 5 days
HOPI
The Patient was Apparently asymptomatic 8 days back then he developed fever which is on & off , also has dry cough since 6 days
No headache, burning micturition, nausea, vomiting, loose stools.
PAST HISTORY:-
Not a known case of HTN,DM,TB,EPILEPSY.
Personal history
Diet mixed
Appetite normal
Sleep adequate
Bowel and bladder regular
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%
ultrasound
PROVISIONAL DIAGNOSIS:
VIRAL PYREXIA WITH THROMBOCYTOPENIA.
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.
21/08/2022
Soap notes
S : fever spikes subsided
O:
Patient is conscious and coherent
BP : 110/80
PR : 94 bpm
RR : 22 cpm
Temp : 97.3° F
GRBS 12 am - 152 mg/dl
7am - 134 mg/dl
CVS : S1,S2 heard no murmurs
Resp system : BAE +
P/A : soft and non tender
CNS : NAD
A :
Viral pyrexia with thrombocytopenia
P
★IVF 2× NS , 2×RL @ 75ml/hr
★Tab PCM 650mg PO SOS
★Tab ZOFER 4mg PO SOS
★Syp ASCORIL-D 15 ml PO BD
★BP & Temp monitoring 4th hrly
Soap notes 22/08/2022
S : fever spikes subsided
O:
Pt was conscious coherent co operative
PR : 82 bpm
RR : 18 cpm
BP : 90/60 mm of Hg
Temp : 98.6 °F
GRBS @8am : 132mg/dl
CVS : S1,S2 + No added sounds
Resp system : BAE + , Clear
P/A : soft and non tender
CNS : NAD
A:
Viral pyrexia with thrombocytopenia
P :
★IVF 1× NS , RL @ 75 ml /hr
★tab ZOFER 4mg/PO/SOS
★tab DOLO 650 mg PO SOS
★Syp ASCORIL - D 15 ml/ PO/TID
★tab Pulmoclear PO/BD
Soap notes 23/08/2022
S: Fever spikes subsided
O :
Pt is conscious and coherent
PR :78bpm
RR : 18 cpm
BP : 110/70 mmHg
Temp : 98.6 F
GRBS@8am - 132mg/dl
CVS : S1 , S2 + , No added sounds
R/S : BAE + , clear
P/A : soft and non tender
CNS: NAD
A : viral pyrexia with thrombocytopenia
P :
★IVF 1×NS,1×RL @75ml/hr
★TAB.ZOFER 4mg/PO/SOS
★TAB DOLO 650mg PO SOS
★SYP.ASCORIL - D 15 ml/PO/TID
★TAB.PULMOCLEAR /PO/BD
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