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
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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