65 year old male with fever, cough and generalised weakness

​This is an online e log book to discuss our patient’s deidentified health data after taking his/her guardian signature and informed consent. Here we discuss our individual patient problems through series of input from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e log book also reflects my patient centered online learning portfolio and your valuable inputs on the comments 

A 65 year old male came to the hospital with fever since 20 days, cough since 10 days , and generalised weakness 

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic one month back and then had fever which was intermittent associated with chills and high grade fever which is relieved on medication and cough since 10 days associated with sputum and had generalised weakness associated with body pains.

HISTORY OF PAST ILLNESS 

Patient had tuberculosis one year back 

No known diabetes, hypertension, epilepsy 

PERSONAL HISTORY 

Married

Occupation: daily wage labourer 

Apetite: loss of Apetite 

Diet: non vegetarian 

Bowels : irregular 

Micturition: normal

No known allergies 

No known family history 

GENERAL EXAMINATION

No pallor,cyanosis,malnutrition,dehydration, icterus, clubbing of fingers/ toes , oedema of feet 

VITALS 

Temperature:102F

Pulse rate:92/min

Bp:110/80mmhg 

Spo2:98%

SYSTEMATIC EXAMINATION 

CVS

No thrills , cardiac murmurs

Cardiac sounds: S1 S2

RESPIRATORY SYSTEM 

No dyspnoea, wheeze 

Position of trachea : central 

Breath sounds : vesicular 

ABDOMEN 

Shape of abdomen: scaphoid 

Tenderness: no 

Palpable mass: no 

Hernial orifice : normal 

Bowel sounds: yes 

CNS

Conscious 

Speech: normal 

PROVISIONAL DIAGNOSIS:

Viral pneumonia 

TREATMENT:

Inj.Augmentin 1.2gm/IV/bd

Inj.neomol 1gm/IV 

Tab.azithromycin 500mg po/od

Inj.pan 40mg IV/OD 

Neb with duolin,budecort 6th hourly 

Syp. Benadryl 10ml po/tid 

Tab.pcm 650mg po/tid 

Tab.ultracet po 

Tab.shelcal -ct po/od 

Tab.livogel 120mg po/od 

Tab.nodosis 500mg po/od





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