GENERAL MEDICINE CASE DISCUSSION

SUPRIYA GAGIREDDY 42

Hi,I am supriya 5th sem medical student.This is an online elog book to discuss our patients 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 problems with collective current best evidence based inputs.This E-log book reflects my patient centered online learning portfolia.

CHIEF COMPLAINTS

A 54yrs old female who is a housewife from Nalgonda came to opd with chief complaints of SOB since 2days and generalised weakness.

HOPI:
Patient was apparently asymptomatic 8 months ago then she developed SOB which is insidious in onset and continuous in nature which aggravates on walking and also on lying down.It gets relieved on sitting position [grade 3 SOB].It is also associated with dry cough.She also has genearalised weakness and also fever since 8months which is intermittent in nature.

She consulted a local doctor in Nalgonda from where she got to know that she has low Hb levels for which she underwent blood transfusion and again back in July her Hb levels were found low[5.0g/dl] and again she underwent blood transfusion[2units] after which her Hb levels increased from 5.0 -8.0g/dl.She again developed SOB and generalised weakness since 2days for which she again consulted a local doctor in Nalgonda and got her tests done. Now her Hb levels have got down within a month that is around 3.8g/dl.So she came here for blood transfusion.



PAST HISTORY:

H/O similar complaints in past

She has h/o TB since 6 yrs for which she used ATT drugs

She also has a h/o hyperthyroidism since 4yrs for which she used carbimazole

She also has h/o arthritis since 4yrs

she is not a k/c/o DM,HTN,asthma,epilepsy

No h/o any allergy to food or drugs

TREATMENT HISTORY:

ATT drugs

Carbimazole

SURGICAL HISTORY:

She had underwent surgery for cleft palate when she was 3yrs old

she also had underwent hysterectomy 30yrs back due to heavy bleeding

FAMILY HISTORY:

No similar complaints in family

PERSONAL HISTORY:

Appetite:normal

Diet : mixed

Sleep: Adequate

Bowel and bladder movements : regular

Addictions : none

GENERAL EXAMINATION:

Patient is conscious , coherent , cooperative and well oriented to date , time and place

Patient is ill built and undernourished

BP: 120/70 mm hg

PR: 70 bpm

RR: 20cpm

temperature: 98.6*F 

SPO2: 95%

GRBS: 106mg/dl

pallor : present







icterus: absent

cyanosis: absent

clubbing : absent

lymphadenopathy:absent

pedal edema: absent 





SYSTEMIC EXAMINATION:  

CVS: S1 and S2 + , no murmurs 


https://youtube.com/shorts/vPJ2zUeO-f4?feature=share


CNS :NAD

P/A : Soft and non tender

RS :BAE+

INSPECTION: 

Tracheal position is central

Symmetrical chest 

PALPATION:

All inspectory findings are confirmed by palpation

Trachea is central

Chest is symmetrical with

AP diameter : transverse diameter =5:7

Symmetrical expansion of chest

Vocal fremitus is felt

PERCUSSION:

Resonant on percussion

AUSCULTATION:

Breath sounds are normal

  • INVESTIGATIONS:



































































  • PROVISIONAL DIAGNOSIS:

     

   ANAEMIA 

TREATMENT

02/08/2022


Normal Diet


IVF-NS J @30ml/hr


Inj.Lasix 20mg /IV/BD


Tab. Orofer -XT /PO/OD


I/O charting


Vital monitoring


Inj. Vit-B12 1500micro gm /Im/ OD


Tab. Moximac 600mg po/OD


Neb. Salbutamol /1resp/stat


03/08/2022


Normal Diet


IVF-NS J @30ml/hr


Inj.Lasix 20mg /IV/BD


Tab. Orofer -XT /PO/OD


Neb with Mucomyst /2Rsp 


Neb with salbutamol /1Resp /BD


I/O charting 


Monitor vitals and fever charting

https://youtu.be/jmADwuXzRBU


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