A 40 year old patient with cough and fever

Hi, I am K. Komali , 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient-centered online learning portfolio

                        CASE SHEET

CHIEF COMPLIANTS:

A 40 year old patient who was a farmer and mostly encountered with pesticides by occupation and resident of Ramannapet came to clinical OPD with 
Fever from 5 days
Cough since 3 days ( without sputum )
Pain during cough
Tightness of chest
Irritation in respiratory tract and chest area
Difficulty in breathing

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 5 days ago after which he experienced fever, difficulty in breathing and chills. He was taken to a local hospital the next day and was given few tablets and injection to control fever and cold.
After that he again started experiencing cough without any sputum, tightness of chest and shortness of breath for which he was immediately brought to hospital.

HISTORY OF PAST ILLNESS: 

No diabetes mellitus
No hypertension
No TB
No CAD
No leprosy
No bronchial asthma
No epilepsy

FAMILY HISTORY:

No significant family history

PERSONAL HISTORY:

Appetite : Normal
Diet : Mixed
Bowel movement : regular
Sleep : Inadequate
Addictions : 
 Alcoholic, takes regularly upto 90ml

PHYSICAL EXAMINATION
A. General Examination

Conscious and coherent
Thin built and malnourished
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No pedal edema

Vitals:

Pulse rate : 90/minute
Blood pressure : 120/70 mm of Hg
Respiratory rate : 26/ minute
SpO2 : 92mm of Hg

INVESTIGATIONS:

Arterial Blood Gas Analysis:
Chest X ray:
Provisional Diagnosis:
Community Acquired Pneumonia

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