65 YEAR OLD MALE PATIENT WITH PRODUCTIVE COUGH AND SPUTUM
A 65 year old male patient came to the op woth a cheif complaints of severe cough with sputum since 1 week ,fever since 6 days , and pain in the chest region
HISTORY OF PRESENTING ILLNESS
The patient had severe cough since 1 week , that was productive and the sputum was whitish in colour, there are no aggrevating factors but relived on medications (ascoril)temporarily . The fever was low grade,and continuous type, and was associated with neck pain since 3 days and lower back ache since 6 days,There was pain in the chest region which was of dragging type,He also complained of loose stools since 6 days.
PAST HISTORY
No history of hypertension, diabetes mellitus , tuberculosis,CAD,CVA,thyroid issues,asthma .
PERSONAL HISTORY
Mixed diet
Normal appetite
Normal sleep
Normal urination
No burning micturition
Normal bowel movements
General examination : the patient was moderately bulit well nourished, conscious and coherent
No pallor, icterus , cyanosis ,clubbing, lymphadenopathy ,edema
Bp : 100/60
RR:14bpm
Pulse: 60 ( low volume )
Temp: febrile