E log of 32 year old male
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A 32 year old male who is a village revenue assistant by occupation came to opd with c/o
Fever since 10 days
Productive cough since 5 days
HOPI:
Patient was apparently asymptomatic 10 days ago then he developed fever which is low grade , intermittent type, Mainly during night time and relived temporarily with medication , associated with chills and rigors.
C/o productive cough with mucoid sputum, intermittent type, which is mainly during night time.
-Generalised weakness present
-Not associated with burning micturition ,cold,rash ,body pains ,vomitings,loose stools
-Associated with sob on doing ordinary activity( grade 2 mmrc) since 5 days , relieves on taking rest
Past history:
Not a k/c/o DM,HTN ,CVA,CAD ,ASTHMA
Patient had a trauma history 5 years back his leg was injured totally, bandage applied for it
He is know case of HIV (diagnosed 1 year ago )and he is on medication
Personal history :
Diet-mixed
Appetite-normal
Sleep-adequate
B and bladder movements-normal
Addictions-toddy -12 years back ,occasionally
Daily routine -
The patient is a village revenue assistant by occupation.He wakes up by 7 am freshens up and takes his breakfast at 8:00am and goes to his work,Then he takes lunch break at 1pm and goes back to work ,he takes dinner by 8 pm and sits with his children for some time the goes to sleep at 9pm.
His daily activities are disturbed. Due to his symptoms
GENERAL EXAMINATION:
-No palor
-No Icterus
-No cyanosis
-No lymphadenopathy
-No edema
-No clubbing of fingers
Temperature:
Febrile - 99.9°F
Pulse: 82 beats per minute
Respiratory rate: —16 cycles per minute
Blood pressure: 130/90 mm of Hg
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills
No murumurs
Cardiac sounds: S1, S2 present
Respiratory system:
Bilateral airway entry present ,crepts heard in IAA ,left ISA ,Right IAA
Abdomen:
shape scaphoid
umbilicus central , inverted
no increase in local temp,no tenderness
No spleenomegaly
No hepatomegaly
BS+
Investigations:
Diagnosis:
Pyrexia under evaluation
?pulmonary Tb
? community acquired pneumonia
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