62YR/M WITH HISTORY OF FEVER

MEDICAL CASE DISCUSSION

 

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I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my cmpetancy i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

May 20, 2021

Aishwarya Gannoji,

Roll no:35.

CASE PRESENTATION:

62 year old male came to GM OPD  with chief complaints of

 1. Fever since 2 days.

HISTORY OF PRESENT ILLNESS:

 

Patient was apparently asymptomatic 2 days back, then he developed 

• Fever was insidious in onset and mild. It was intermittent in character which was relieved on taking medication. It was associated with mild body pains and cold.

          Not associated with:

             ✓ chills and rigor

             ✓ cough

            ✓chest tightness

            ✓chest pain

             ✓palpitations

            ✓shortness of breath.

PAST HISTORY:

Patient is known case of  Diabetes mellitus since 7 years.

He is on Tab. Metformin 500mg PO/OD.

                Tab.Glimi M2 PO/OD.

NOT A KNOWN CASE OF HYPERTENSION, CAD,CVA, EPILEPSY,ASTHAMA.

       

FAMILY HISTORY:

No significant family history  • none of his family member are tested covid positive.

PERSONAL HISTORY:

                       • Diet - mixed

                       • Appetite-decreased appetite

                       • Sleep-adequate

                       • Bowel and Bladder - regular

                       • Addictions- alcoholic  

GENERAL  EXAMINATION:

                                                                                    The patient is conscious , coherent, cooperative and well oriented to time , place and person . He is moderately built and nourished .

            

    • pallor- absent

    • icterus -absent

    • cyanosis - absent

    • clubbing - absent

    • lymphadenopathy - absent

    • edema- absent 

 VITALS:

     temperature - 98.4 F

     pulse rate - 94 /minute

     respiratory rate - 22/min 

     blood pressure - 120/ 80 mm of hg

     spo2 - 98% 0n RA 

    

            

 LOCAL EXAMINATION  :                                          

No external injuries and scars.

SYSTEMIC EXAMINATION:

(during the time of admission)

RS - Normal vesicular breath sounds heard

CVS - S1 and S2 heard

PA - Soft and non tender

CNS - intact.

INVESTIGATIONS:

                          HEMOGRAM

           

                

                 C REACTIVE PROTEIN

                RENAL FUNCTION TEST

                 LIVER FUNCTION TEST

                              D DIMER

              GLYCATED HAEMOGLOBIN

                         GRBS CHART

              

              PROVISIONAL DIAGNOSIS:

viral pneumonia secondary to COVID 19.

 TREATMENT:

Tab GLIMI 2mg PO/OD

Tab GLIMI 0.5mg PO/OD

Tab Metformin 500mg PO/OD

Tab DOLO 650mg PO/SOS

Tab Levocetrizine 5mg PO/OD/NA

GRBS 8th hourly

Temperature charting 9th hourly

Temperature charging 4th hourly

Tab Dolo 650mg PO/OD

GRBS Monitoring 

Tab Metformin 500mg 

Tab Glimiperide 2.5mg 

Tab Glimiperide 0.5mg 

Tab Metformin 500mg.

I would like to thank Dr. Rakesh Biswas sir for providing this opportunity.