Thursday 21 April 2016

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

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