A 65 year old male with fever, generalized weakness and body pains.

This is an online e log book to discuss our patients deidentified health data after taking his / her guardian signature in informed consent. Here we discuss our individual patient problems through series of input from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This E log book also reflects my patient centered - online learning portfolio and your valuable inputs on the comments. 

A 65 year old male came to the hospital with fever ,dry cough, loss of appetite, generalized body weakness since four days . 
History of present illness 
Patient was apparently asymptomatic one month back then had fever on and off since then early  relieved on medication with no diurnal variation which is associated with chills and high grade fever and cough since 7 days associated with sputum Which is white in colour and had loss of appetite and generalized weakness since then and also had body pains . 
History of past illness
Tb 1 year back - used medication
No known history of hypertension, DM, CAD, epilepsy. 
Personal history 
Diet - mixed
Appetite - lost
Sleep - disturbed 
Bowel movements - normal
Bladder movement - normal
General examination 
Vitals
Temp- 102 f
Pulse rate - 92/ min
Respiration rate - 12/min
Bp - 110/80 mm of Hg
Spo2 - 98%
GRBS- 126mg %
No known clubbing, icterus, clubbing of fingers/ toes, cyanosis, lymphadenopathy, oedema of feet, malnutrition, dehydration. 
Systemic Examination 
Cvs
No thrills , cardiac murmurs
Cardiac sounds s1s2+
Respiratory
No dyspnoea, wheeze, 
Position of trachea central
Breath sounds vesicular
Abdomen 
Shape scaphoid
No tenderness ,Palpable mass,  free fluid, bruits, 
Hernial orifice normal
Liver, spleen non palpable 
CNS
Patient is Conscious, coherent
No neck stiffness, kernings sign 
Diagnosis 
Viral pneumonia 
Treatment
Inj. Augmentin 1.2 gm/iv/bd
Inj. Neomol 1gm/iv
Tab. Azitromycin po/od
Inj. Pan 40mg iv/od
Neb. With duolin, beudecort 6th hourly 
Syp. Benadryl 10mlpo/tid
Tab. Pcm 650mg po/tid
Tab ultracet po
Tab shelcal -ct po/od
Tab livogel 120mg po/ od
Tab nodosis 500mg po/od









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