General medicine e-log 4

 Hi, I’m A Naga pravallika 6th Sem medical student.Thjs is an online e-log book to discuss our patient health data.This also reflects my patient centered online learning portfolio 

   A 55 year old male patient came to causality with cheif complaints of cough associated with pain in the left side chest pain since 10 days.
 
HOPI-
           Patient was apparently asymptomatic since 15 days and then developed fever since 10days.
  FEVER- intermittent 
                  Low grade fever 
                  Not associated with chills and rigor 
  Associated with COUGH - since 10 days 
                                            Productive cough with white color, non-foul smelling sputum 
Cough is associated with Left side chest pain since -
    PAIN-non radiating 
                 Not associated with sweating 
Cough associated with SHORTNESS OF BREATH since 10 days 
NEGATIVE HISTORY 
                                  No history of burning micturition& loose stools 
 No history of hypertension 

PAST HISTORY-
                            No history of surgeries &trauma 

FAMILY HISTORY-
                             No significant family history 

PERSONAL HISTORY-
                                  Sleep - not adequate 
                                   Appetite -reduced     
                                  Bowel&bladder -normal 
                                  Allergies- no allergies 
                                  Alcohol- occasional 
                                 Cigarette- 2-3 /day since 
GENERAL EXAMINATION- 
                                    Patient was conscious, coherent and well oriented with time ,place and person.

                          No pallor 
                          No icterus 
                          No cyanosis 
                          No lymphadenopathy 
                          No edema 
VITALS -  BP -120/80
                   Pulse - 70bpm
                   Temperature-
                    Respiratory rate -

Comments

Post a Comment

Popular posts from this blog

General medicine

Image
 Hi, I’m A Naga pravallika 3rd Sem medical student.Thjs is an online e-log book to discuss our patient health data.This also reflects my patient centered online learning portfolio  An 47 year old women,tailor by occupation,resident of Nalgonda was admitted in the hospital on 2/6/22(Tue) with complaints of fever , body pains , loss of appetite. 10 years back she developed joint pains she was treated at private hospital asymptomatic until 8 months back.post covid vaccine she was treated with medication.patient had a history of decreed vision at age of 15 years.  Patient history Diet-mixed Appetite-decresed Sleep-disturbed General Examination  Conscious Coherent Pallor No icterus No clubbing of fingers No lymphadenopathy  No edema  A rash was present on the face   
Read more

General medicine e-log 5

Image
 Hi, I’m A Naga pravallika 6th Sem medical student.This is an online e-log book to discuss our patient health data.This also reflects my patient centered online learning portfolio   A 60 year old male patient came with cheif complaints of shivering of right arm and forearm since 2years    HOPI -                 Patient was apparently asymptomatic 2years back. He then developed shivering of right hand and forearm   Insidious onset and gradually progressive. Initially localised to fingers and later radiated to right arm  C/O- numbness , tingling          Pain & Tingling in the right thigh          Shivering is present throughout the day intensity increases and decreases. PAST HISTORY -                             No history of trauma or injury in the past           N/ K/C/O- diabetes ,BP, TB ,epilepsy. FAMILY HISTORY -                                    No significant family history  PERSONAL HISTORY -                       Appetite - normal                              Sleep-adequat
Read more