63M with fever dry cough hoarseness of voice body pains
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I have 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 diagnosis and treatment plan.
CHIEF COMPLAINTS
A 80yr old male came to the opd with fever headache hoarseness of voice body pains weakness since 5 days,dry cough since 1 month
HISTORY OF PRESENTING ILLNESS
The patient was apparently asymptomatic 5 days ago then he developed fever hoarseness of voice weakness, dry cough since 1 month
Insidious in onset and gradually progressive aggrevated at nights and eating spicy food relieved on taking paracetamol
No C/O TB asthma epilepsy diabetes
PAST HISTORY
Patient has a history of hypertensionsince 4-5 years and on medication(telsartan40)
FAMILY HISTORY
No significant family history
PERSONAL HISTORY
Occasional drinker
GENERAL EXAMINATION
Pallor negative
No signs of icterus cyanosis clubbing lymphedenopathy edema
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