A 42yr old female patient came to general medicine OPD with cough ,shortness of breath and difficulty in swallowing.

26 December,2022.

I am G.Anisha(rollno:45)3rd sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio.

A 42 old female patient who is a tailor and labourer by occupation came to general medicine opd with cheif complaints of cough,shortness of breath and difficulty in swallowing and fever.


HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 month back and she had cough which is dry and not induced on medication. patient had fever 1 month back which is high grade and continuous and it lasted for 1week and then got reduced .Now again she had fever since 1day,high grade,continuous not associated with chills and rigors.

PAST HISTORY :
No HTN
No epilepsy
No TB
No diabetes
No asthma
No CAD


DRUG HISTORY:
No significant 


PERSONAL HISTORY: PERSONAL HISTORY -
Dirt -mixed
Appetite - decreased
Bladder and Bowel movement - regular
Sleep -normal
No known allergies
No history of addictions
Menstrual history-regular 


FAMILY HISTORY-
No relevant family history 


PHYSICAL EXAMINATION -

GENERAL EXAMINATION -
Patient is conscious, coherent, comfortable and co-operative
Moderately built, moderately nourished
Pallor
No icterus
No cyanosis
No general lymphadenopathy
No clubbing of fingers 
Pedal edema absent

 
VITAL SIGNS-
Temperature: 101 F
Pulse: 139 /min
BP: 110/80mm of Hg
Respiratory rate: 26 cpm
SpO2: 96%

SYSTEMIC EXAMINATION 
CVS:
Cardiac sounds: S1 and S2
No thrills
No cardiac murmurs

RESPIRATORY SYSTEM:
No dyspnea
No wheeze
Central location of trachea
Vesicular breath sounds -decreased
Dull note on percussion-left lower lung


ABDOMEN-
Abdomen is scaphoid.
No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds are not heard

CENTRAL NERVOUS SYSTEM 
Conscious 
Speech- normal
Signs of meningeal irritation - 
      no neck stiffness
Cranial system - intact 
Motor system - intact 
Sensory system - intact 
 Cerebeilar signs
  Finger nose- in coordination
  Knee heel - in coordination


Provisional diagnosis:
Dengue ,thrombocytopenia,pleural effusion.





LAB INVESTIGATIONS:











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