32 year old male with fever and productive cough.

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.

• 32y male fever since 10 days ,productive cough since 5 days

August 03, 2023

•  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 retropositive case. (diagnosed 1 year ago )and he is on medication

Personal history :

• Diet-mixed
• Appetite-normal

• Sleep-adequate
• Bowel 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 o
• 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