General medicine E- log

HI,Iam Aziza  of 6thsem medical student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects patient centred online learning portfolio

A 70year old male patient with chief complaints of SHORTNESS OF BREATH and fever since 3 days

HOPI:
patient was apparently asymptomatic two months back then he developed shortness of breath during eating,walking for a distance of 0.5km relieved on medication
Fever since 3 days which is intermittent relieved on medication

PAST HISTORY:
Developed jaundice 2 months back
Duodenal ulcer D1 1 month back
Stunt placed in the heart two months back due to myocardial infarction

PERSONAL HISTORY
Diet mixed
Appetite normal
Sleep adequate
Bowel nd bladder normal
No burning micturition
Addictions-alcohol

GENERAL EXAMINATION:
Patient was conscious coherent and well oriented with time place and person..

icterus is Present 
No cyanosis,clubbing,koilonychosis,lymphadenopathy,edema
VITALS:
BP-100/55
PULSE-70beats/min
TEMP-normal
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
inspection normal
Percussion normal
Auscultation-no abnormal breath sounds

Git examination : 
Cvs examination




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