General medicine elog
October 22 ,2021 GM CASE I. AKHILA Roll no-158 Below is an E-log describing patient centered data approach and discussion regarding patient de- identified health data. CHIEF COMPLAINTS A 30 yrs old male patient came to casuality with chief complaints of fever since 7days ,shortness of breath,cough,cold and myalgia HITORY OF PRESENTING ILLNESS - ---fever since 7days ---shortness of breath ---cough,cold myalgia PAST HISTORY -- -no known past history of diabetes, hypertension,asthma, epilepsy PERSONAL HISTORY: H/o tobacco and alcohol consumption Not a known case of DM VITALS Patient was C/C/C PR : 98BPM. RR : 18 CPM BP : 90/70 mm of Hg. Spo2 : 98 % at RA. GENERAL EXAMINATION- Patient is thin built and malnourished No pallor, icterus, cyanosis, lymphadenopathy, Clubbing PROVISIONAL DIAGNOSIS The patient may have had covid before Currently the patient is suffering from viral fever BIOCHEMICAL INVESTIGATIONS ULTRASOUND REPORT ECG SERUM ELECTROLYT