General medicine elog

 11 October, 2023

42 yr old female with cough and fever

Hi, I am Ananya Nayak, 5th sem medical student. this is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.

A 42 yr old female,housewife by occupation came to the opd with chief complaints of fever and cough since 1 week.

HISTORY OF PRESENTING ILLNESS:*
The patient was apparently asymptomatic 1 week back then developed fever and cough.
The fever was of high grade, intermittent in nature and associated with chills, headache and weight loss.
The cough is associated with sputum that is non blood stained, no foul smell and white in colour.There was also hoarseness of voice.
There is no history of night sweats, nausea, vomiting and there was no diurnal variation in the temperature.

*PAST HISTORY:*
N/K/C/O DM, TB, HTN, Asthma or epilepsy.

*PERSONAL HISTORY:*
Appetite - normal
Sleep - adequate
Diet - mixed
Bowel and bladder movements - regular
No addictions

*FAMILY HISTORY:* irrelevant

*GENERAL EXAMINATION:*
Patient was C/C/C and slightly malnourished
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No pedal oedema

*VITALS:*
BP: 80/60 mm of Hg
PR: 81 bpm
RR: 20 cpm
Temp: Afebrile






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