march 06 2023

I'm Muskan BDS 3rd year student.

March 6

This is an E-log to discuss case scenario of a patient with their guardian's help.
I have been given this case to solve in an attempt to understand topic of patient, clinical data analysis to develop my competency in reading and comprehending clinical data including history, clinical findings i,nvestigation and come up with diagnosis and treatment plan .



A .60 year old female resident of Nalgonda came to OPD on 4 march 
CHEIF COMPLIANT:
Dry cough: since 2 days
Shortness of breath since 1 day
Chest pain 1 day
Fever 1day and decrease in urine output.
 HISTORY OF PRESENT ILLNESS:
 Patient was apparently asymptomatic 2 days ago then she then she started compling of dry cough since 2 days
Type of cough : dry cough
Onset of cough: insidious with gradually progressing in nature.
Chest while cough.
Patient also compliance of shortness of breath since 1 day .
Grade 3 - shortness of breath on doing less than ordinary work
Oliguria - less than 500 ml a day.
PAST ILLNESS:
not a know case of BP, asthma, diabetes,TB 
PERSONAL HISTORY: 
Diet : mixed
Bowel and bladder: normal
Appetite: normal
Addiction: no
Allergy: no
GENERAL EXAMINATION: 
Patient is conscious, coherent, cooperative, well oriented to time and place and person.
Pallor: not seen 
Edema : seen
Clubbing:not seen

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