General medicine E-log

 A 55 YR OLD MALE CAME WITH COMPLAINTS OF FEVER, COUGH, LEFT  SIDED CHEST PAIN

Hi, I am Aziza Ferdose 3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

A 55 year old male patient cae to casuality with cheif complaints of:
Cough since 10 days associated with left sided chest pain

HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 15 days back then he developed fever which was intermittent, low grade,  not associated with chills and rigor

Fever was accompanied by cough which was productive with white colour, non foul smelling sputum

Left sided chest pain which is severe, non radiating , aggrevated on coughing
Shortness of breath since 10 days

NEGATIVE HISTORY:
No history of burning micturition
and loose stools

PAST HISTORY:
History of Hypertension since 15 days
No history of surgeries and trauma

FAMILY HISTORY:
No significant family history

PERSONAL HISTORY:
Diet mixed
Appetite reduced
Bladder and bowel normal
Addictions
      Cigarette - 2-3/day since 30 yrs
       Alcohol  ocassionally

GENERAL EXAMINATION:
Patient was concious , coherent , well- oriented with time,place and person

No pallor
No icterus
No cyanosis
No lymphadenopathy
No oedema
No koilonychosis
VITALS:
BP :120/80 mmHg
Pulse: 70 beats/ min
Temp :
Respiratory rate :