A 36 year old man with fever and nausea since last 2 month

Pt. Botanical i.d.-albizia464chinensis01

This is a HIPAA de-identified open-online-patient-record with initial information in duty-doctors notes as well as patient's voice, posted here summer 2016 after collecting informed patient consent (form downloadable here).

Pt. Voice history-

Age- 36/m
Occ.- labour
Add.-

vital signs
B.P.-110/80
Pulse- 74
R.r.-21

C/o-
Fever since 60 day,
Nausea during walking,
Dry mouth,headache

Past h/o-
Malaria -2 month ago
Typhoid - 45 day ago
Past dr. Notes

Personal h/o-
Nutrition- normal, bidhi smoking, alcohol,
Environment - village

Objective examination
Nails are normal
Abdominal normal
Skin normal
Posture normal
Gait normal

Present dr. Notes

Analysis
Pyrexia unknown origin (puo)..?

Planning
Current medication continue

A 40 year old man with chest pain and cough since 3 month

Botanical i.d.-aegle462marmelos01

This is a HIPAA de-identified open-online-patient-record with initial information in duty-doctors notes as well as patient's voice, posted here spring 2016 after collecting informed patient consent (form downloadable here).

Pt. Voice history-

Knowledge of pt.

Age -40/m
Occ- shopkeeper
Add.-

Vital signs
B.p.-110/90
Pulse- 74
Tem.- 98
R.r.- 21
C/o-
Chest pain since 3month during coughing

past medi. H/o-
Thyroid medi. Continue 1year( thyronorm 25 mg - early morning empty stomach.
Head injury -before 1year ago

Family h/o-
Paternal
Father- hypertension
Mother -  thyroid
Sister- thyroid
Maternal-no

Persnol h/o-
Nutritional - poor nutrition and pt. Is Intake tobacco and smoking everyday and alcohol two time in a month.
Environmental h/o- cloudy area.

Objective exami.
posture- normal

Nails normal

Skin normal
Gait normal
Heart regular rate and rthythm,
Abdomen- bowel sound normal

Analysis
lf. lung Pleural effusion,

Planing
pleural fluid rapping

Day one report of pleural fluid exami.-