GENERAL MEDICINE ELOG 5



A 48 year old male patient came with the chief complaints of cold, cough and fever since 10 days.


HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 10 days back, then he developed 

      Fever : sudden in onset

                   Intermittent in nature

                   High grade

Not associated with nausea, vomiting, chills, rigors or headache.

The cough was associated with sputum which was non blood stained.

 

PAST HISTORY:

No history of similar complaints in the past.

N/K/C/O diabetes, hypertension, TB, Asthma or epilepsy.


PERSONAL HISTORY:

Appetite - normal

Sleep - adequate 

Diet - mixed

Bowel and bladder movements - regular

No addictions


FAMILY HISTORY: Not significant 


GENERAL EXAMINATION:

Patient was C/C/C and slightly malnourished 

No pallor

No icterus

No cyanosis

No clubbing

No lymphadenopathy

No pedal oedema







VITALS:

BP- 140/80 mm Hg

PR- 76 bpm

RR- 20 cpm

Temp- Afebrile



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