Morning Report 10/9/2019

Patient Profile N.M.H a 59 Y.O male patient, married with 5 kids, lives in alzarqa. he was admitted via pulmonary clinic on Thursday 5/9/2019 at 12 PM

Chief Complaint complaining of Fever

History of Presenting Illness The patient was doing well until 1 month & 2 weeks ago; as he started complaining of continuous fever, he went to AlHekma Hospital ER and did some investigations but due to insurance problems she came to PHH. fever (it was documented orally 36.5C, and axillary 39.3C, relieved by cold compresses)

History of Presenting Illness green associated with fatigue, pallor, cough with sputum ( green in color ), SOB, sore throat, chills and night sweats, loss of appetite, weight loss (11 kgs over 13days) Patient has left side facial palsy Mood instability NO rash NO change in mental state, No dizziness / light-headedness No cemotherapy No chest pain

Systemic Review

CVS CVS: no palpitations, no lower limb edema, no orthopnea RS RS: hoarseness, no wheezes, no hemoptysis GI GI: No dysphagia, no odynophagia, no regurgitation, no heart burn, no nausea/vomitting, no diarrhea/constipation, no abdominal pain, no melena, no hematochezia. No yellowing/redness of skin GU GU: no dysuria, no frequency, no urgency, no nocturea, no hematuria no change in urine color. MSS MSS: no myalgia, no arthralgia, no recent trauma, no jaw claudication, HEMATOLOGY HEMATOLOGY: no bleeding tendencies, CNS CNS: no loss of consciousness, no seizures, no altered sensation, no numbness, no difficulty w speech, no double vision, no confuse, Endocrine Endocrine: cold intolerance,

Past Medical History Hx of GERD ( YEAR AGO ) No previous similar attacks No hx of asthma No hx of heart problems No hx of malignancies No HTN No DM No hx of thyroid disease No hx of URTI

Past Surgical History No past surgeries

Drug History hx of unknown antibiotics Hx of ranitidine DICLOGESIC Suppositories: (Diclofenac) known drug allergies to: vancomycin & imipramine Patient has been taking for the past 5 days aspirin & niacin on empty stomach

Family History His mother & sister have DM & HTN No hx of the same complaint No hx of ca No hx of thyroid diseases No hx of IHD No hx of lung diseases No hx of hematological disease

Social History Patient stop smoking 1 mounth ago (, 1 packet daily for 32 years) No Alcohol intake No hx of recent travel No pets

Summary F.M.S a 24 y/o female patient admitted via ER complaining of sudden, persistent fever associated with fatigue, pallor, cough with sputum SOB, sore throat, chills and night sweats, loss of appetite, weight loss

DDx Most likely PNEUMONIA Less likely SARCOIDOSIS TB SLE MALGNANCY