A 56 YEAR OLD MALE

his is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.



This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.



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 diagnosis and treatment plan.
A 56 YEAR OLD MALE CAME WITH THE C/O FEVER SINCE 20 DAYS
GENERALIZED BODY PAINS SINCE 10 DAYS
LOSS OF APPETITE SINCE 15 DAYS
NO H/O LOOSE STOOLS,COLD,COUGH,PAIN ABDOMEN,MALENA

HISTORY OF PRESENT ILLNESS:
FEVER SINCE 20 DAYS WHICH WAS LOW GRADE, INTERMITTENT, SUDDEN IN ONSET,NOT ASSOCIATED WITH CHILLS AND RIGORS, RASH.
BODY PAINS GRADUALLY PROGRESSIVE IN NATURE AND INCREASED WITHOUT TAKING FOOD.
HEADACHE SUDDEN IN ONSET, DRAGGING TYPE, PRESENT IN B/L FRONTAL REGIONS, SOMETIMES DIFFUSES TO PARIETAL REGION, INCREASED WITH FEVER SPIKES (AT NIGHT TIMES)

PAST HISTORY: 
K/C/O HTN SINCE 5 MONTHS
2 MONTHS BACK HE HAD SURGERY FOR HYDROCELE
 
PERSONAL HISTORY
DIET- MIXED
APPETITE-DECREASED
SLEEP-REDUCED
REGULAR BOWEL AND BLADDER MOVEMENTS
ADDICTIONS-DRINKS ALCOHOL SINCE 10 YRS (3 TIMES/MONTH ) STOPPED 2 YRS BACK
SMOKES CIGARETTE SINCE 10 YRS ( DAILY 2 TO 3 PER DAY) STOPPED 2 YRS BACK

VITALS
PR-98 BPM
BP-100/80 MM HG
GRBS-101MG/DL
RR-16 CPM

GENERAL EXAMINATION
NO PALLOR, ICTERUS, CLUBBING, CYANOSIS, PEDAL EDEMA, LYMPHADENOPATHY

SYSTEMIC EXAMINATION
CVS-S1,S2 HEARD
RS-BAE +
PER ABDOMEN- SOFT,NON TENDER
CNS- NFND

PROVISIONAL DIAGNOSIS
UNDIFFERENTIATED FEVER
 K/C/O HTN SINCE 5 MONTHS

INVESTIGATIONS




On 6/9/21

FEVER CHART








TREATMENT :
ON 4/9/21
1.INJ .OPTINEURON 1 AMP IN 100 ML NS IV ) OD
2.INJ.NEOMAL 100 ML IV/SOS
3.INJ.PANTOP 40 MG IV/OD
4.INJ.ZOFER 4MG IV/SOS
5.TAB.PCM 650 MG PO/TID
6.TAB.ULTRACET PO/QID
7.BP/PR/TEMP/RR 4TH HRLY
8.TAB.TELMA 40 MG PO/OD

ON 5/9/21

1.INJ .OPTINEURON 1 AMP IN 100 ML NS IV ) OD
2.INJ.NEOMAL 100 ML IV/SOS
3.INJ.PANTOP 40 MG IV/OD
4.INJ.ZOFER 4MG IV/SOS
5.TAB.PCM 650 MG PO/TID
6.TAB.ULTRACET PO/QID
7.BP/PR/TEMP/RR 4TH HRLY
8.TAB.TELMA 40 MG PO/OD1.INJ 

ON 6/9/21
1 INJ.OPTINEURON 1 AMP IN 100 ML NS IV ) OD
2.INJ.NEOMAL 100 ML IV/SOS
3.INJ.PANTOP 40 MG IV/OD
4.INJ.ZOFER 4MG IV/SOS
5.TAB.PCM 650 MG PO/TID
6.TAB.ULTRACET PO/QID
7.BP/PR/TEMP/RR 4TH HRLY
8.TAB.TELMA 40 MG PO/OD