19M fever and cough since 3days

A 19YEARS OLD MALE CAME WITH THE CHIEF COMPLAINTS OF FEVER & HEADACHE 
November 09, 2023

This is an online E log book by Faizal.m 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments 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. 

CHIEF COMPLAINTS:

A 19 year old male patient came with the chief complaints of:
- fever, since 3days
- Headache since 2days

HOPI:-

The patient is apparently asymptomatic since 3
 days back.  
Then he got fever, sudden in onset, continuous. Not relieved on medication ( PCM ) , 
Not associated with chills and rigor
headache sudden in onset and continuous
Cold and cough since 3days
Associated with body pain
No burning micturation

PAST HISTORY:
No history of HTM , 
No Asthama,
No epilepsy,
No CVD , 
No DM


PERSONAL HISTORY:

Diet: Mixed
Bowel : normal 
Sleep : irregular 
Micturition: no burning micturation 
Appetite: normal
Habits: no alcohol addiction 


Family history:
 No significant family history 

GENERAL EXAMINATION: 

The patient is examined in a week lit and well ventilated room
Moderately built and moderately nourished

No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy


VITALS:

Temperature: febrile

Pulse: 82beats per minute, regular

Respiratory rate: 13 cycles per minute

Blood pressure: 120/90 mm of Hg

MEDICATION:
T - Azithromycin 500mg × 5days
T - PCM 650mg × 3days
T - Levocetirizine × 3days

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