35 years old male , with chief complaint of fever and chest pain

Hi, I am Y.Shasshank , 5th semester medical student. 

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 patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. 

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.

Chief Complaint 

35 years old male ,resident of mriyalgudem came to OPD with chief complaint of fever associated with body pains since 1 month and chest pain since 1 week

 

History of presenting illness

Patient was apparently asymptomatic 1 month back

Then he developed- fever which was low-grade , intermittent,sudden in onset. Their is evening rise in temperature. Aggravated while exposing to sun , relieved by medication and rest.

And the chest pain was insidious in onset , intermittent and dragging type , aggravated by working/ walking , relieved by medication.

Past history

No h/o DM, hypertension, epilepsy, asthma , tb ,

Thyroid , blood transfusion.

 No past surgical history.

Family history

No significant history

Personal history

Married 

Mixed diet 

Normal appetite

Regular bowel and bladder movements

* Inadequate sleep 

* Had an habit of consuming alcohol occasionally 

General examination

Patient was conscious, coherent , cooperative

 

No pallor 

No icterus

No cyanosis

No clubbing of fingers

No pedal edema 

No lymphadenopathy

Vitals 

Temperature- febrile 

Bp- 110/ 70 mmhg

Pulse - 95 bpm

SYSTEMIC EXAMINATION 

CVS - S1, S2 heard 

CNS - Higher motor functions intact 

PA - Soft and non tender 

RS - BAE+ , NVBS +