60 year male with chief complaints of fever and shortness of breath

              27th December,2022
Hi, I am Gaddam shreya of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.
The patient’s consent was taken verbally prior to history taking and examination of her condition.

A 60 year old male patient who was farmer by occupation came to general medicine opd with chief complaints of shortness of breath since 2 months , fever since 20 days.

 HISTORY OF PRESENT ILLNESS-
Patient was apparently asymptomatic 2 months.
Then he developed shortness of breath which is insidious in onset.
SOB is not associated with wheeze, orthopnea, PND.
20 days back he developed fever which is low grade associated with chills and evening rise of temperature is observed.
No cough, hemoptysis, chest pain,chest tightness.

PAST HISTORY -
Not a known case of hypertension, DM.
No history of epilepsy,syphilis, CAD, asthma,TB.

FAMILY HISTORY -
No significant family history.

PERSONAL HISTORY -
Diet-mixed
Appetite- decreased
Bladder and bowel movements - regular
Sleep- adequate 
Addictions-
consumes alocohol twice a week.
Also have habit of smoking.
ALLERGIC HISTORY - no known allergies

DRUG HISTORY - patient is not under any medication.

PHYSICAL EXAMINATION -
GEBERAL EXAMINATION
Patient is conscious, coherent, comfortable and co-operative
Moderately built,nourished 
No pallor 
No icterus
No cyanosis
No general lymphadenopathy
No clubbing of fingers 
Pedal edema - absent.

VITAL SIGNS-
Temperature: 101F
Pulse:106bpm
BP: 110/70mm of hg 
Respiratory rate: 20cpm
SpO2: 99 percent

SYSTEMIC EXAMINATION
CVS:
Cardiac sounds: S1 and S2
No thrills
No cardiac murmurs

RESPIRATORY SYSTEM:
No dyspnea
No wheeze
Central location of trachea
Vesicular breath sounds

ABDOMEN-
Abdomen is scaphoid
No tenderness
No palpable mass
Non palpable liver and spleen
Free fluid present 
Bowel sounds are not heard

CENTRAL NERVOUS SYSTEM 
Conscious 
Speech- normal
Signs of meningeal irritation - 
no neck stiffness
Cranial system - intact 
Motor system - intact 
Sensory system - intact 
 Cerebeilar signs
    Finger nose- in coordination
    Knee heel - in coordination

PROVISIONAL DIAGNOSIS
Right upper and middle lobe consolidation.

INVESTIGATIONS DONE-
2D echo, ultrasound,CBP,blood urea,serum creatinine, serum electrolytes, LFT, ECG

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