General medicine case discussion

April 17th Case scenario.......

Hi, I am M.Yamini , 5th sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.

CASE SHEET:A 32 year old male, farmer by occupation,came from miryalaguda to general medicine opd ,date of admission:11/April

Chief complaints:
Fever since 9 days , associated with cough from 3 days & chest pain

HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic 9 day's back, suddenly he develops fever, Intermittent fever with evening rise of temperature,fever with chills & headache.
He took medication at home,fever not relieved on medication.then he came to our hospital.
Headache:on frontol region,throbbing type of pain, bilateral,not radiating,
Headache relieved on medication.
Cough:3 days back he developed dry cough
Chest pain:on right side
Wt loss :not significant

PAST HISTORY :Not significant

PERSONAL HISTORY:
Diet:Mixed
Appetite: Normal
Sleep : inadequate due to fever
Bowel& Bladder movement s: Regular
No food & drug allergies
Addictions:kini daily & occasionally alcoholic
Family history:Not significant.

General examination
Patient was conscious
Coherent
Co operative
Moderately built
Moderately nourished
Pallor: present
Icterus: absent
Cyanosis: absent
Edema: absent
Lymphadenopathy: absent

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