Patient name: Be than, Beta
Data source: patient
Chief Compliant & ID: Mr. Be than is a 24 y/o had visited a doctor six months ago complaining persistent headache
History of Current Illness
This 24 years gentleman had visited a doctor six months ago. The man states he started having headache and shivering two days before he visited the doctor. He noticed that a headache was becoming more persistent although he only experienced the shivering in the evening hours. A headache began from the cerebral part and radiated with time to the entire head. The patient states that he started experiencing the headache one evening when he was watering his
Vegetables. Later, he started having poor appetite, eye pain, vomiting, fussiness, and had a sore throat.
Medical history
1993: The patient was diagnosed with cancer on July 7, 1993. He began medication immediately and stopped after three months after feeling some relieve. During the same year, the patient visited the doctor several times, and head received frequent medical checkups for diabetes.
Heart disease: experienced high palpitations and received treatment in 1997.
Family History
Mother: 46, alive and in good health conditions
Father: 68, alive and under treatment for diabetes. The patient has one brother and two sisters, all of them alive. One of the patient’s sister is has been diagnosed with diabetes, and she under medication. The family has a history of diabetes.
Social History
Smoking: the patient is a chronic tobacco user. He has smoked tobacco for four years since he completed his high school education. He smokes more than two packets of cigarettes every week. The patient smokes tobacco mostly early in the morning, late in the evening, and quite often when he is stressed.
Alcohol use: the patient is addicted to alcohol, which he has consumed for more than three years. He drinks anytime he gets money. He confesses that he is drinks two glasses every evening when leaving work.
Medications: the patient has no history of abuse of illegal drugs. However, the patient has occasionally been prescribed for ibuprofen (Advil) and Acetaminophen due to frequent headaches.
Review of Symptoms
HEENT:
The patient had a sore throat that had caused him to have an obstructive sound. He complained a persistent headache that often leads to eye pains. He also had a serious running nose and ear pain.
Cardiovascular:
The patient had rapid heart rate/ palpitations
Biopsy: the patient did not show any symptoms of cancer.
Gastrointestinal:
The patient did not complain of a change in stool consistency or pattern. He complains of frequent vomiting which occurs mostly at night. He also complains diarrhea.
Musculoskeletal:
The patient complains pains in the backbone and neck pain
Neurological:
He complains numbness and shows signs of hallucinations
Physical examination:
The pulsation rate 90, the blood pressure 167/98, body temparatures38 degrees. The patient was shivering/ had chills and general body weakness due to poor appetite. Also, the patient had flushing/ hot skin. He also felt dizzy and was hyperthermia. He had clear lungs although there were some crackles in the bases. Additionally, there is decrescendo murmur produced by intercostal muscles. The neck moves with a bit of resistance although it does not show signs of adenopathy. The trachea is stiff with some mucus accumulating in the trachea.
