27 year old male with fever, reduced appetite and burning sensation in throat and chest

Hi , I am Rushikesh Zade,3rd semester student.  This is an online elog book to discuss our patients health data after taking his consent.  This also reflects my patient centered online learning portfolio.

Chief complaints

27 year old male who is a resident of Chottupal presented to the OPD with fever since 15 days, generalised weakness. 

History of present illness

Patient was asymptomatic 15 days back. Then he developed generalised weakness, decreased appetite, low grade continuous fever since last 15 days subsided on medication. 
He has throat burns since a few days and acid reflex. 
He went to a RMP in Chottupal who gave him a glucose and antibiotic injection and then his weakness subsided for a while. 
He also took some fruit juices at home which reduced weakness. 

Personal history

No hypertension
No diabetes
No epilepsy
No syphilis
No CAD
NO TB
Normal sleep
Regular bowel
Decreased appetite
Micturition normal

Daily routine

Wakes up at 5
Walks for a while
Comes back home at 9:30am
Natural activities
Goes to work

Family history. 
No significant family history

General examination

Conscious, coherent and cooperative
Pallor pressent

No icterus
No clubbing
No lymphadenopathy
No pedal edema
Prowprly nourished

Vitals

Pulse-84
Bp- 110/90
SpO2- 96%
Temperature -

Systemic examination 

Investigations


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