44M PTB DM
Case History and Clinical Findings : PATIENT CAME TO OPD WITH COMPLAINTS OF COUGH SINCE MONTHS, LOSS OF APPETITE SINCE 2 MONTHS , FEVER SINCE 1 AND HALF MONTHS HISTORY OF PRESENT ILLNESS : PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS AGO, THEN HE DEVELOPED COUGH WHICH IS PRODUCTIVE (THICK, WHITISH SPUTUM) NON BLOOD TINGED, NON MUCO-PURULENT , NO DIURNAL VARIATION CO FEVER WHICH IS HIGH GRADE, INTERMITTENT, RELIEVED WITH MEDICATION ASSOCIATED WTH CHILLS AND RIGOR WITH NO DIURNAL MARIATION. CO LOSS OF APPETITE SINCE 2 MONTHS. NO C/O BURNING MICTURITION, COLD, HEADACHE, BODY PAINS. NO C/O CHEST PAIN, PALPITATIONS, SOB. PAST HISTORY K/CO TYPE 2 DM SINCE 8YRS (ON TAB SITAGLIPTIN 500MG + METFORMIN 1000MG PO/OD) NOT AK/C/O HTN, CAD, CVA. GENERAL EXAMINATION: THE PATIENT IS CONSIOUS, COHERENT, COOPERATIVE, WELL ORIENTED TO TIME, PLACE AND PERSON, MODERATELY BUILT AND NOURISHED. VITALS BP: 110/70 MMHG PR: 88 BPM RR: 18 CPM TEMP, 984 F CVS: S1, S2 HEARD, NO MURMURS