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 ELECTROLYTES 


SERUM CREATININE 


LIVER FUNCTION TEST 


BLOOD UREA



 





























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