Telemedical Consultation - Systemic Viral Infection

20mar24 -

Telemedical consultation -

male ~70, running nose 3 weeks ago with purulent discharge, followed by moderate cough, no fever, no diarrhea, with body weakness, poor appetite. No history of contact with PUI or confirmed COVID.

With the video chat, I was able to assess his external appearance or health. I could sense he was weak. No fever at the moment (since 3 weeks ago). No colds. Occasional dry coughs now. He claimed body weakness and poor appetite have been stable, no increase, no decrease in degrees during the past 2 weeks. He is on maintenance meds for hypertension and diabetes mellitus. My primary clinical diagnosis: systemic viral infection (nonspecific). My recommendations: continue to rest at home (both physical and mental wise); force himself to eat more with the goal of maintaining adequate nutrition to boost resistance; drink plenty of fluid for adequate hydration; stress management; continue to be productive (computering and vibering) but controlled; and to do a little structured exercise which is lacking at this point (advised to do a little intentional stretching and flexing exercises 5 to 10 minutes 3x a day. No medicines prescribed at the moment (he just has to continue his maintenance meds for hypertension and diabetes). He can stay home but has to do self-monitoring and observation. He and his wife will update me tomorrow.