A 50 year old male came to casualty with c/o fever since 10 days

A 50 year old male came to casualty with c/o fever since 10 days



This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.

Intern : N Joshua Paul

A 50 year old male came to casualty with c/o fever since 10 days


HOPI - patient was apparently asymptomatic 10 days back, then he developed fever, insidious in onset, associated with chills and rigors , and it was relieved on medication

H/o cough with sputum, whitish in colour, non blood stained.

H/o SOB ( grade 1-2 )

No H/o orthopnea, PND, chest pain.

No H/o burning micturition , decreased urine output, pedal oedema.

No H/o bleeding manifestations.


PAST HISTORY- Not a k/c/o HTN, DM, CVA, CAD, TB, Asthma, or thyroid disorders. 


PERSONAL HISTORY- 

Diet - mixed

App- normal

Sleep- adequate 

B and B - regular

Addictions- pan daily 


Allergic history:-

No history of any kind of allergies to food/drugs


Family history:- 

No significant family history 







GENERAL EXAMINATION:- 

THE PATIENT IS CONSCIOUS COHERENT AND COOPERATIVE , WELL ORIENTED TO TIME, PLACE AND PERSON. 

NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ODEMA ; LYMPHADENOPATHY


TEMPERATURE:- 98.2F

PR:92bpm

BP:90/60 mmHg

RR:17cpm


SYSTEMATIC EXAMINATIONS:-


CVS:S1 S2+,NO MURMURS

CNS: NAD

RS:BAE+ ; NVBS 

P/A:SOFT ; NON TENDER ; NO ORGANOMEGALY 


PROVISIONAL DIAGNOSIS:- fever under evaluation.


Investigations-








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