Gm case 6

Hii..I'm srivally, 3rd year bds student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patients centered online learning portfolio

                     CASE HISTORY 
Chief complaints :
A 19year old male , complaints of 
Fever since 30days
Shortness of breath since 15 to 20days
Headache and lower backpain since 30days
Cold since 3months

History of present illness:
Patient was apparently asymptomatic 1month ago then he developed low grade , intermittent type of fever which is aggrevated since 15days , mainly during the night time , temporarily relieved on medication not associated with cold and cough , burning micturition , rash on body associated with bodypains and headache , lower backache . Shortness of breath since 15days which is present even on rest, which aggravates after having food . Bloating is present , chest tightness is present . 

History of past illness:
NEGATIVE HISTORY:
Hypertension-No
DM - No
CVA -No
CAD-No
TB -No
Asthma-No
Surgical history-No

Personal history:
Appetite-lost
Diet- mixed
Bowel- regular
Micturition - burning sensation
Known allergies -no
Addictions - alcohol occasionally

Family history:
Not significant

General examination:
Pallor-no
Icterus-no
Clubbing-no
Cyanosis-no
Lymphadenopathy-no
Pedal edema-no

Systemic examination:
Gastrointestinal system:
Shape of abdomen- scaphoid
Tenderness-no
Palpable mass-no
Hernial orifice-no
Free fluid-no
Liver-not palpable
Spleen- not palpable
Bowel sounds -no
Cardiovascular:
Thrills -no
Cardiac sounds-s1 s2 heard
Cardiac murmurs-no

Provisional diagnosis:
Viral pyrexia.


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