63 year old male patient with viral pneumonia
Following is the view of my case: (history as per date of admission)
63 YEAR OLD MALE PATIENT WITH VIRAL PNEUMONIA
63 year old male patient came to the hospital with the chief complaints of
cough with expectoration since 6 days
fever since 6 days
shortness of breath since 6 days
myalgia since 6 days.
History of present illness.
Patient was apparently asymptomatic 6 days ago then
He developed cough with expectoration which is insidious in onset, progressive in nature, it is mucoid, minimal, non foul smelling and non blood stained. There are no aggravating factors , it relieved with medication.
History of fever since 6 days which is insidious in onset, high grade and intermittent type. It is associated with chills not associated with rigors.
He also has shortness of breath since 6 days which aggravates on exertion.( MMRC grade- 1 or 2).
He has myalgia since 6 days.
He has no complaints of chest pain,wheeze or decrease in urine output
Past History
There is no history of TB, asthma, hypertension, diabetes mellitus, cardiovascular diseases.
No H/O previous surgeries.
There is H/O chest trauma 30 years back.
Personal history
Appetite- normal
Diet -mixed
bowel and bladder -regular
Sleep- adequate
Addictions-He is a chronic smoker since 35 years
He is chronic alcoholic since 40 years
No known allergies.
Family history
No significant family history.
General examination
Patient is examined in a well lit room with informed consent.
He is conscious, coherent, co-operative,well oriented to time,place and person.
He is moderately built and moderately nourished.
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Edema - absent
Vitals:
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