40 years old male with community acquired pneumonia with right upper lobe,middle lobe,lower lobe consolidation and left upper lobe

Hello, I am Y.N.Indu Vaishnavi,a 3rd semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio

 40 years old male  resident of nalgonda who is farmer came to the hospital with the complaints of 


CHIEF COMPLAINTS
C/o  Fever since 3 days 
C/o cough (dry cough) since 3days 
C/o shortness of breath grade 4 since 3 hours 


HISTORY OF PRESENTING ILLNESS
Patient  was apparently asymptomatic  3days ago then he had fever  associated with chills and rigors  then he developed dry cough,And then developed SOB Grade 4 since 3 hours.
No h/o cold, nausea, vomiting, loose stools.



PAST HISTORY
Not a known case of
Diabetes 
Hypertension
Tb 
Asthama
Epilepsy
Cvd
Chemotherapy

FAMILY HISTORY
Not significant
PERSONAL HISTORY
Diet - mixed
Appetite - Decreased 
Bowel and bladder - adequate
Allergies -odlu dust
Addiction -  intake of alcohol 
90ml daily 

Daily routine before 10 days
5:00 woke up
6-7:00 had breakfast and tea
10:00 went to work
2:00 lunch
3:00 taddy daily + alcohol 
8-9:00 dinner( when take alcohol he never had breakfast.without alcohol he will have food)
 9:30 sleep

GENERAL EXAMINATION
Thin built and malnourished 

Vitals
Temperature : Afebrile 
Pulse: 90
BP:120/70 mm/ hg
RR :26
SPO2 : 92%

Pallor : ABSENT 
Icterus : ABSENT 
Clubbing :ABSENT
Cyanosis :absent
Lymphadenopathy: absent
Pedal edema: absent

SYSTEMIC EXAMINATION
CVS
Apex beat 6 th intercoastal space
No thrills
S1 S2 heard
No murmurs

ABDOMEN EXAMINATION


RESPIRATORY SYSTEM

dyspnoea wheeze+
Central trachea 
Bilateral air entry +
Bilateral basal crepts +

Investigation 
















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