35F with fever, weakness, SOB

 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.

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.




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:












TREATMENT:

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


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