Case Presentaion

A years old old male with

Fever,Cough ,Breathlessness
 Particulars of The Patient
Name
Age yr
Sex Male
Marital Status
Address
Religion Islam
Occupation Student
Date of Admission
Date of Examination
Chief Complaints
● Fever for days
● Cough for days
● Breathlessness for days
● Weightloss for days
History of present illness

According to the statement of the patient he

was resonably well __weeks back.Since
then,he had been suffering from low grade fever
with evening rise of temparature which is
accociated with profuse night sweat.
He also complains of cough with expectoration
of blood mixed sputum which persists all day
and night.Not associated diurnal veriation ,dust
or fumes and cold weather.
Patient also complains of mild and heaviness
breathlessness of right chest which is not
associated with excrtion or lying position
 General Examination

Appearance :
Body Built :
Co-operation :
Decubitus :
Anaemia :
Jaundice :
Cyanosis :
 General Examination
(contd.)

Koilonychia :
Leukonychia :
Clubbing :
Edema :
Neck Veins : Not engorged
Lymph Nodes :
Thyroid Gland : Not enlarged
 General Examination
(contd.)

Bony Tenderness : Absent

Skin Condition : No pigmentation
Dehydration : present
Pulse : beats/min, regular in rhythm
Blood Pressure :
Respiratory Rate : 22 breaths/min
Weight : kg (reduced kg over one month)
Temperature : 99 ֯F
 Complete Blood Count
Date

Hb

ESR

Total count of WBC

Neutrophil

Lymphocytes

Total platelet count

MCV

MCH

MCHC
CXR P/A View