52M with PYREXIA ,SOB,BODY PAINS

October 30, 2023

30 October 2023

Hi ,I am Ananya Nayak, 6th sem medical student. This is an online elog book to discuss our patient’s health data after taking his consent.This also reflects my patient centered online learning portfolio.

Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patient’s clinical problems with collective current based evidence based inputs.

A 52 yr old male patient farmer by occupation came to the OPD with chief complaints of fever since 10 days .

HISTORY OF PRESENT ILLNESS-
Patient was apparently asymptomatic 10 days back.Then he developed fever which was high grade,sudden in onset, intermittent in nature aggrevated during night and on exertion. It is associated with body pains(aggrevated on exertion),chills and rigor.It is not associated with cough,cold,vomitings,headache.
Patient has complaints of Shortness of breath on exertion since 10 days.No PND,Orthopnea.

PAST HISTORY-
K/C/O DM since 5yrs
N/K/C/O asthma,Epilepsy, thyroid,HTN.
No h/o blood transfusion.

PERSONAL HISTORY-
Appetite -decreased
Diet-mixed
Sleep-adequate
Bladder movements -burning micturition
Bowel movements-regular
He has been a drinker since 20 yrs but stopped 1 month ago.

FAMILY HISTORY-Not significant

GENERAL EXAMINATION-
The patient is conscious, coherent and cooperative. The patient id moderately nourished and well built.
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No pedal edema

VITALS -
Temperature-afebrile
BP-110/70 mmHg
RR-12 cpm
PR-72 bpm

SYSTEMIC EXAMINATION-

CVS-
S1,S2 are heard
No murmurs
Thrills absent

RESPIRATORY EXAMINATION-
Normal vesicular breath sounds are heard.
Bilateral air entry present
Trachea is in midline
No wheeze
No dyspnea

ABDOMEN EXAMINATION-
Inspection
Shape -Distended
Equal movements in all quadrants
No visible pulsation and localised swellings. Hernial orifices intact.
Umblicus-inverted
Skin over abdomen is normal
Palpation-
Liver,spleen not palpable.
Mild Tenderness present in the left and right lumbar region.
Bowel sounds heard.

CNS EXAMINATION-
Conscious
No signs of meningeal irritation.
Speech-normal
Cranial nerves-normal
Gait-normal
Knee heel incoordination-No
Finger nose incoordination-No