35F with fever, weakness, SOB.

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  This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.




This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

Radhesh Mahankali.


35 year old female came to general medicine OPD chief complaints of :

Fever since 1 month

SOB since 3 months

Weakness since 1 month


HOPI:


Patient was apparently asymptomatic 3 months ago
then she developed SOB On prolonged walking,which was releived on taking rest.
Then she had developed weakness which was  generalized in nature 1 month ago

She developed fever of low grade in nature 1 month ago intermittent in nature and releived on medication. She Then developed high grade fever 3 weeks back which were associated with chills and rigors for which she visited an hospital in suryapet 
and was diagnosed as anemic.

No H/o orthoprea; PND.
No H/o cold and cough.
No H/o blood in stools.

Menstrual history:


No H/o of clots in the menstrual blood.



DAILY ROUTINE:


PAST HISTORY:

No history of Hypertension, Diabetes, Asthma, Epilepsy, TB.



FAMILY HISTORY: NOT SIGNIFICANT.


PERSONAL HISTORY:

Diet : Mixed.

Appetite: Normal.

Bowel and bladder: Regular.

Sleep: Adequate.

Addictions: None

Allergies: No known allergies.


VITALS:

TEMP:

BP:

PR:

RR:


GENERAL EXAMINATION:

Patient was conscious,coherent and cooperative, thin build and moderately nourished, well oriented to time, place and person.

Pallor : pallor present.

Koilonychia: Present

Icterus: absent.

Clubbing: absent.

Cyanosis: absent.

Lymphadenopathy: absent.

Edema : absent.





SYSTEMIC EXAMINATION:

CVS:

Inspection : 
Shape of chest- elliptical 
Trachea: central
No engorged veins, scars, sinuses and visible pulsations
JVP - Raised

Palpation :
Apex beat felt in 5th inter coastal space 
No thrills and parasternal heaves felt.

Auscultation : 
S1,S2 are heard
no murmurs

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical , B/L symmetrical
Trachea- central
Both sides of the chest are moving equally on respiration.
No scars, sinuses, engorged veins, pulsations seen


Palpation:

Trachea - central
Expansion of chest is symmetrical. 
Vocal fremitus - normal

Percussion:

Resonant note on both sides, all areas.

Auscultation:

Bilateral air entry present.
Normal vesicular breath sounds heard.

P/A:

Inspection:

No distention.
Umbilicus: inverted.
No scars, sinuses and engorged veins , visible pulsations. 
Hernial orifices- free.

Palpation:

Soft and non-tender.
Spleen and Liver not palpable.



CNS EXAMINATION:

Conscious, coherent and cooperative 
Speech- normal
No signs of meningeal irritation. 
Cranial nerves- intact
Sensory system- normal 

Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes: Right     Left. 
Biceps      ++             ++
Triceps.    ++            ++
Supinator ++            ++
Knee.        ++             ++
Ankle        ++             ++

PROVISIONAL DIAGNOSIS:  ANEMIA SECONDARY TO MENORRHAGIA.

INVESTIGATIONS:
12:4:2023
      












   




16:4:2023:








TREATMENT:

INJ: IRON SUCROSE IV /OD WEEKLY THRICE
TAB PARACETAMOL
TAB OROFER: PO/OD





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