Noon Case Discussion

14/05/57

Patient Profile

76
. .

Chief Complaint

Present Illness

10 :


7 :

.


4 :


. .

Past Illness

Personal History

,
1 20
10 pack/year

Family History

Review of Systems

General 1.5 . 10

Head
Eyes

Ears

Nose
Throat


Respiratory


Cardiovascular


Gastrointestinal


Genitourinary

Musculoskeletal

Neurological



Extremities

Hematologic

Physical Examination

Vital sign at .
BT 39.1 c BP 121/65 mmHg
PR
96 /min RR 20/min
Vital sign at ward
BT 37.5 c BP 121/72 mmHg
PR
76 /min RR 16/min
Weight kgHeight cm
BMI kg/m2
General Appearance
A middle age Thai male, good consciousness, cooperative, mild pale, no jaundice, no pitting edema

HEENT
Head -normal structure
Eyes -mild pale conjunctivae, anicteric sclerae
Ears - normal external auricle
Nose - no red or swelling, no discharge
Mouth&Throat no oral ulcer , tonsil and
pharynx not injected
Neck no superficial cervical
lymphadenopathy
Cardiovascular No cyanosis , pulse full &regular , No
heaving , No thrill , Normal S1 S2 , no murmur

Repiratory Dyspnea , no accessory muscle used,

normal chest contour , trachea in midline ,decrease
lung expansion at RLL ,dullness on percussion at
RLL , decrease breath sound at RLL ,fine crackles
at RLL
Abdomen- soft, not tender, no hepatosplenomegaly
Neurological E4V5M6 , good consciousness , well
co-operative ,orientation to time,place and person,
Muscle power grade 5 all extremity
Skin no petechiae, no rash
Extriemities no pitting edema

Problem lists
Acute Dsypnea for 4 days
Acute Fever for 7 days