GENERAL MEDICINE ELOG 3 ( 11/10/23)

 A 42 year old female with cough and fever.

Hi , I am Harsha Chandana ,a 5th semester 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 year old female came to the OPD with the 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:

Temp: Afebrile

BP: 80/60 mm

PR: 81 bpm

RR: 20 cpm





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