General medicine elog

 22 October, 2023

Hi ,I am Ananya Nayak, 6th sem medical student. This is an online elog book to discuss our patient’s health data after taking her consent.This also reflects my patient centered online learning portfolio.

A 50 yr old female patient came to the OPD with the chief complaints of fever and cough since 6 days.

HISTORY OF PRESENTING ILLNESS-
Patient was apparently asymptomatic 6 days back.
Then she developed fever which was sudden in onset, intermittent in nature and high grade. It was associated with headache, chest pain.It was not associated with nausea,vomiting and no diurnal variations.
She also developed cough which was associated with sputum. The sputum was white in colour,non foul smelling and non blood stained.

PAST HISTORY-
H/o HTN since 3 years and DM since 3 months.
N/K/C/O asthma,Epilepsy ,TB

PERSONAL HISTORY-
DIET-Mixed
Sleep-adequate
Appetite-normal
Bowel and bladder movements-regular
No addictions

FAMILY HISTORY-Not significant

GENERAL EXAMINATION-
The patient is C/C/C and well built.
No pallor
No cyanosis
No icterus
No clubbing of fingers
No lymphadenopathy
No pedal edema

VITALS-
BP-130/70 mm Hg
RR-16 cpm
Pulse rate-74 bpm
Temperature-afebrile









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