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80 yr old male patient with fever and dry cough

This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.


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 and not associated with chills and rigor. Then patient developed dry cough since 6 days
No headache, burning micturition, nausea, vomiting, loose stools.

Daily routine; 
He wakes up at 7:00am in the morning and takes his breakfast at 8:00am. Which includes rice and dal. After breakfast he watches tv . In the afternoon he sleeps at 12:00pm to 2:00pm. Ha takes his lunch at 3:00pm.
Then at 7:00pm he takes his dinner. And sleeps at 9:00pm.

PAST HISTORY:-
Not a known case of HTN,DM,TB,EPILEPSY.

Personal history 
Diet mixed
Appetite normal
Sleep adequate
Bowel and bladder regular
Addictions: 

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%

Systemic examination: 
CVS: s1 and s2 are heard .no cardiac murmurs.

RS: No dyspnea,no wheezing,trachea is central .
       Normal vesicular breath sounds are heard.

ABDOMEN :
Shape of abdomen is scaphoid. Abdomen is soft.
No palpable mass , no tenderness, no hernial orifices.

CNS : NAD




Chest x-ray:


ECG:




ultrasound

LFT

RFT

CBP

BLOOD GROUPING AND RH TYPING

PROVISIONAL DIAGNOSIS:
 VIRAL PYREXIA WITH THROMBOCYTOPENIA.
20/08/2022

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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