If I’m to write my own case history, it would look like something like this.
25/c/male
Premorbid : nil
p/w -
fever x 1/7, low grade, a/w arthralgia, myalgia, no chills and no rigors.
cough x 4/7, productive, minimal greenish sputum. on & off since last month.
sorethroat. lost of voice.
no SOB, no orthopnea, no PND.
no dyspepsia, no dysuria
BO+PU normal
PMhx - nil
PShx - nil
Family history - not able to assess since no voice
Social history - HO in melaka GH. Known contact with PTB patients. Known contact with possible H1N1 patients.
Drug hx - not a fan of medications.
o/e :
lungs clear, air entry equal.
cvs - DRNM
abdomen - SNT
cns no abnormalities.
throat - injected, no enlarged tonsils
no regional LN palpable.
Ix - FBC, Busec, throat swab c+s
Refused for H1N1 throat swab as pt scare of hospitalization (I’m already ‘hospitalized’ what). Refused for blood C+S. Refused for CXR as patient is not keen for radiation, lazy to go to xray room. Sputum AFB and C+S not seen because pt could not cough out the sputum.
Imp : TRO Pneumonia. TRO H1N1. TRO PTB.
FBC taken by Dr. Gan - super painful.
Gan.
FBC - 146/13.5/295/43
neutrophils increased.
Given T. Augmentin 675mg tds, T. PCM 1g tds, Thymol gargle.
T. EES still on the way.
2.1.2010 and I’m already sick!! Only 3 more days to end posting. Duh.
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