Fever since 7 days and Dry cough (80 year old man) GM - CASE 4
23rd August 2022
CASE STUDY 4
Hello, I am Saloni .S. Gangotri , a 3rd semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.
CASE SHEET:
CHIEF COMPLAINTS:
c/o
- fever since 7 days
- dry cough
HISTORY OF PRESENT ILLNESS:
Patient was apparently normal but developed fever with no known cause 7 days back and also dry cough.
ASSOCIATED DISEASES:
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PAST HISTORY:
-no known history HTN, DM, CAD, TB, Epilepsy.
PERSONAL HISTORY:
Used to smoke tobacco, left few years back.
Regular Bowel movements.
Has normal micturition with no burning sensation.
Has no known allergies.
FAMILY HISTORY:
Has no history of Diabetes Mellitus, No HTN, No Cardiac Strokes, No cancers.
DRUG HISTORY:
GENERAL EXAMINATION:
-No palor
-No cyanosis
-No lymphadenopathy
-No icterus
-No edema of feet
-No clubbing of fingers
-Temp - normal
-GRBS -
VITALS:
Temperature: febrile
Pulse: 90 beats per minute
Respiratory rate: 18 cycles per minute
Blood pressure: 100/60 mm of Hg
SPO²: 98
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills
No murumurs
Cardiac sounds: S1, S2 present
Respiratory system:
No dyspnea
No wheezing
Breath sounds heard: vesicular? yes
Abdomen:
Shape : Scaphoid
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard
Central Nervous System:
Conscious and Alert
Speech: Normal
INVESTIGATIONS:
Biochemical investigations:
ECG:
2D ECHO REPORT :
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ULTRASOUND REPORT :
GRAPHIC SHEET:
PROVISIONAL DIAGNOSIS:
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