65 YEARS OLD MALE

 This 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. 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.

 65 YEARS OLD MALE CAME TO CASUALITY WITH 

CHIEF COMPLAINTS:  

 FEVER Since  3 Days

 Generalised weakness since 3 days 

Loss of appetite since 2 days 

Shortness of breath since 2 days 

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 3 days ago then he developed fever low grade ,not associated with chills and rigors ,relieved with medication ,no diurnal variation.Generalised weakness since 3 days .shortness of breath since 2 days insidious in onset and gradually progressive.No orthopnea,No PND ,loss of appetite is present.

N/h/o vomiting,loose stools ,pain abdomen ,cough ,SOB, excessive sweating,chest pain 

Past history : 

K/c/o HTN since 15 years 

Type 2 DM since 15 years 

Personal history:

Diet - mixed 

Appetite -Normal 

Bowel and bladder - regular 

Sleep - adequate

Addiction - Alcohol intake weekly twice 

Treatment history :

Patient on unknown medication since 15 years for HTN , DM 

Family history: Not significant 

General examination :

Patient is conscious ,coherent ,cooperative

 Moderately Built and Moderately Nourished 

Pallor : absent 

Icterus : absent 

Cyanosis: absent 

Clubbing : absent 

Lymphadenopathy : absent 

Edema : absent

 Vitals :- 

Temp: 101.9F 

BP : 120 / 80mmHg 

PR : 78 bpm 

RR : 30cpm 

GRBS : 220

SYSTEMIC EXAMINATION:

Respiratory system:

Inspection: chest shape normal, 

No scars , no engorged veins 

Movement of chest both sides 

AUSCULTATION :

Bilateral air entry 

Normal vesicular breath sounds 

PALPATION:

Trachea central 

Cvs :

S1,S2 - heard 

No murmur

Abdominal examination: 

Shape : scaphoid

Tenderness -no 

Free fluid -no 

Liver,spleen -not palpable 

CNS: 

Higher mental status intact 

REFLEXES are intact 

No focal neurological deficit 

  

INVESTIGATIONS:  

Hb -13.2

TLC - 11000

Platelets -3.4

DIAGNOSIS:

VIRAL PYREXIA WITH  AKI with DYS ELECTROLYTEMIA WITH K/C/O HTN ,TYPE 2 DM SINCE 15 YEARS