General medicine elog
June 8 2022
Hi, I am Ananya Nayak ,3rd sem medical 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.
A 19 yr old male patient, student ,resident of Nalgonda came to the hospital with complaints of chest pain and shortness of breath
HISTORY OF PRESENT ILLNESS
The patient was asymptomatic 12 days ago and he started developing chest pain in the left side and shortness of breath was also seen.No radiation of chest pain
Fever-on and off since 10 days
He had cough since 5 days
Patient was suffering from shortness of breath which aggrevated while walking and declined at rest.At first he visited a hospital in nalgonda.
No improvements were seen so he approached our hospital.He got admitted here on 1st june and the diagnosis was pulmonary edema.
Onset-insidious
Fever-low grade with chills,cough since 5 days,cold
No vomitings
No burning micturition
No pedal edema
PAST HISTORY
No significant past history
No similar complaints in past.
Not a known case asthma,TB,cardiac disease
PERSONAL HISTORY
Reduced appetite in the initial days
Regular bowels
No drug use
Sleep cycle is normal
Daily routine was going to college and playing cricket .
No constipation
No allergies
FAMILY HISTORY
No such significant family history was found
No Hypertension
No Diabetes
No asthma
No epilepsy
NEGATIVE HISTORY
no vomitings
No headache
GENERAL EXAMINATION
Moderately nourished and well built
Conscious, cooperative ,coherent
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No dehydration
No malnutrition
Pulse rate -80/min
Bp-
SYSTEMIC EXAMINATION -
RS-No swellings
No tenderness on palpation
Skin normal
GIT-no swelling, no tenderness
CNS-
Dominance:Right handed
Memory:able to recognise the family members
Speech:normal
Sensory system: responding to pain
He got discharged on 7 june 2022
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