Title: Translation of Medical Case
The following is a translation of a medical case from Chinese to English:
Patient Information:
- Name: Mr. Zhang
- Age: 55
- Gender: Male
- Occupation: Retired
- Presenting Complaint: Fever and Fatigue
Medical History:
Mr. Zhang has a history of hypertension for 10 years, which has been controlled with medication. He denies any other significant medical history.
Present Illness:
Mr. Zhang developed a fever of 38.5°C accompanied by fatigue and malaise two days ago. He also complains of mild headache and muscle aches. There is no history of cough, sore throat, or shortness of breath. He denies any recent travel or contact with sick individuals.
Physical Examination:
On examination, Mr. Zhang appears tired but oriented. His temperature is 38.6°C, blood pressure is 140/90 mmHg, heart rate is 90 bpm, respiratory rate is 18 breaths per minute, and oxygen saturation is 98% on room air. His lungs are clear to auscultation bilaterally, and there are no palpable lymph nodes. Abdominal examination is unremarkable.
Investigations:
- Complete Blood Count (CBC): Within normal limits
- CRP (CReactive Protein): Elevated at 45 mg/L (normal range: 010 mg/L)
- Chest Xray: Normal
- SARSCoV2 RTPCR: Pending
Working Diagnosis:
Based on the clinical presentation and elevated CRP, the working diagnosis is an acute viral infection, possibly influenza or COVID19. Further evaluation with SARSCoV2 RTPCR is pending to confirm the diagnosis.
Management Plan:
Mr. Zhang is advised to continue symptomatic treatment with antipyretics and rest. He is instructed to monitor his temperature and seek medical attention if his symptoms worsen or if he develops any respiratory distress.
Followup:
Mr. Zhang will follow up in clinic in two days for reassessment and to review the results of his SARSCoV2 RTPCR test.
This concludes the translation of the medical case.
