General Medicine

I'm Maimuna Fathima,3rd year BDS student 
February 13,2023

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,investigation and come up with diagnosis and treatment plan.






A 68 year old female resident of West Bengal came to OPD on 2nd Feb 2023,with chief complaint of 
-Shortness of breath since 7 months 
-Cough(productive) since 7 months 


History of present illness:
Patient was apparently asymptomatic 7 months ago then she developed difficulty in breathing which aggrevated on walking and relieved on rest with no postural variation.
She developed cough which was productive, white in colour and thick in consistency,more at night.


Past history:Not a known case of hypertension,Diabetes,asthma,TB,epilepsy 

Family history:Not significant.

Personal history:
Diet:Mixed
Appetite:Normal 
Bowel and bladder:Regular 
Sleep:Inadequate 
Addictions:None 

General examintion: 
Patient is conscious,coherent,cooperative,well oriented to time place and person 

Vitals:
Afebrile 
Pulse:
BP:
Respiratory rate:
SpO2:

Pallor:Absent
Icterus:Absent 
Cynosis:Absent
Lymphadenopathy:
Edema:Absent 

Systemic examination:
CVS- S1 S2 heard 
No murmur 

Respiratory system: 
Breath sound heard 

Abdomen: 
Soft,non tender 
Bowel sounds heard 
No organomegaly 

CNS:
No abnormality detected

Provisional diagnosis 

Investigations 

Treatment 

Advice 






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