ELOG BASED STUDY

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.

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.

Patient is conscious/ coherent/ cooperative.

BP : 140/90mm Hg

PR : 78 BPM

RR : 18cpm

CVS : S1 S2 HEARD

RS: BAE+ ,  decreased breath sounds in lower( basal ) areas of  left lung.

CNS : NFND 


Investigations:

1)HEMOGRAM:

Hb : 14.4 TLC: 3,800 PC : 1.76

2) ESR : 40

3) LFT: 

TB 1.00 DB 0.25 ALT 47 AST 86

ALP 109 TP 6.5 ALB 4.0 A/G 1.49

4) RFT :

Serum creatinine 1.0 , Urea 21 

Serum electrolytes Na - 139 K - 3.4 Cl - 97




Provisional diagnosis:

Pneumonia c ( Left lower consolidation)

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