General medicine case 8

Anahita behara 

roll no 08

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.


I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including, history, clinical findings, investigations, and come up with a diagnosis and treatment plan 

Case - 8th September 2021

A 25 year old male patient mason by occupation, came to casualty with the complaints of SOB since 1 day and fever since 10 days.

Chief complaint 

- shortness of breath (since one day ) 

-fever since 10 days 


History of present illness 

Patient was apparently asymptomatic one month ago. He took vaccine one month ago for COVID 19, then he developed swelling of Left lower limb ( upto knee) since 20 days.

He developed fever 10 days back which was high grade associated with chills,  subsided with medication and cough with expectoration since 5 days , which was non blood tinged, non foul smelling.


His father in law died two days ago and he didn't take food after that incident , and developed generalised weakness and he SOB since today evening ( 7/9/21).


Not a K/C/O of DM, HTN.

General examination 

Patient is conscious/ coherent/ cooperative.

BP : 140/90mm Hg

PR : 78 BPM

RR : 18cpm

CVS examination 

 S1 , S2 are heard 

Respiratory system examination 

- Bilateral air entry + 

-decreased breath sounds in lower( basal ) areas of  left lung.

Central nervous system 

NFND 


Investigations:

HEMOGRAM:

Hb : 14.4 TLC: 3,800 PC : 1.76

ESR : 

ABG report 




Random blood sugar 


Blood urea 

Serum electrolytes 

Serum creatinine 


Liver function tests 


Chest Xray 


Patient images 





Provisional diagnosis:

Pneumonia c ( Left lower consolidation)

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