General Medicine elog

Hi,I am Ramya Akula ,3 Rd semester medical student,this is an online elog book to discuss our patients health data after taking their consent .This also reflects my patients centered online learning portfolio.

A 23 year old female patient,Resident of yadadri came to the hospital with complaints of dry cough since 5 to 6 months.

This is an ongoing case.I am in the process of editing and updating this elog.

HISTORY OF PRESENT ILLNESS-

The patient was initially asymptomatic 5 to 6 months ago  then she started developing Drycough.At first ,she was admitted in choutupal but there was no prominent response,then she went to Hyderabad and now she is admitted in our hospital.She had a significant weight loss.She had Vomitings in the initial days

Intial weight :34 kg,

Currently:25kgs

Onset-insidious.

Fever- sudden aggregated when she went out in the sun.

Case of Fever ,Drycough during night and Afternoon ,and had a migratory pain from left iliac region to thoracic region.

Date of Admission:06/06/2022

To diagnose her problem Endoscopy was done on 7 th June.

HISTORY OF PAST ILLNESS-

No history of chest pain,Giddiness

No  history of Diarrhoea

No special complaints

No significant past illness

 PERSONALHISTORY

Marital Status:Married

No Constipation

No Diabetes

No Hypertension

Diet-She preferred eating rice ,when she starts eating fruits she vomitted.

Reduced appetite

Bowel:Regular 

Bladder habits- normal.

No other addictions

FAMILY HISTORY:

No significant family history

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative 

Undernourished 

VITALS:

BP:90/50

PR:84

Spo2:99./.

GENERAL EXAMINATION:

No pallor 

No icterus 

No clubbing of fingers 

No cyanosis 

No lymphadenopathy