40yr old male with easy fatiguability

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. 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


40male easy fatiguability
A 40 year old male came with complaints of easy fatigability since 1 year (on & off)
Shortness of breath since 5-6 months
HOPI:
Pt was apparently asymptomatic 1 year back he then noticed having easy fatigability - feeling tired on doing minimal work  insidious in onset and gradually progressive.
C/o shortness of breath since 5-6months insidious in onset and gradually progressive grade ll to grade lll (now)
C/o decreased appetite since 1 month, Normal urine output
C/o blood in stools (on & off) since 1 year with fresh blood streaks.
No h/o constipation, difficulty on passing stools
No c/o fever ,pain abdomen,cold,cough, burning micturition, vomitings,nausea,blood in urine.
No h/o chest pain,orthopnea,PND, palpitations, giddiness, sweating.
C/o generalized weakness of body since
 5-6 months.
Not a k/c/o DM,HTN,CVA,CAD, Epilepsy, Thyroid diseases, Bronchial Asthma.
Personal history:
Ocassionally Alcoholic and stopped 10years back 
Tobacco smoking since 20 years
No h/o blood transfusion in the past

Personal History- 
Diet- Mixed
Appetite- Decreased since 1 month
Bowel & Bladder Movements-H
Sleep - Adequate
Addictions - Chronic Alcoholic Since past 40 years consumed around 90 to 120ml/day
 H/O Smoking since past 20yrs 

Family history- Not Significant

Vitals-
TEMP: Afebrile 
BP: 110/60mmHg
PR: 96 bpm
RR- 18cpm
Spo2- 98% @RA
Systemic Examination:
CVS:
Inspection
Chest wall is bilaterally symmetrical.
No precordial bulge is seen 
Palpation
JVP- Normal
Apex beat -felt in the left 5th intercoastal space in the mid clavicular line 
Auscaltation-
S1&S2 are heard,no murmur found.

RESPIRATORY SYSTEM

Position of trachea- central
Bilateral air entry, normal vesicular breath sounds are heard.
No added sounds

CNS

Patient is conscious ,coherent and co operative , well oriented to time and space.
Speech normal.
No signs of meningeal irritation.
Motor and sensory system- Normal
Reflexes - present
Cranial nerves - intact
 
Provisional diagnosis : Anemia under evaluation 
2D -ECHO

Diagnosis: Iron deficiency Anemia

Treatment:

1.TAB.PAN.40Mg PO/OD
2.TAB.OROFER-XT PO/BD
3.TAB.NEUROBION FORTE PO/OD
Follow up:No limitation in physical activity

Comments

Popular posts from this blog

A 70YRS OLD FEMALE WITH BREATHLESSNESS

54year old male with altered state and hiccups

A 75 year old woman came with chief complaints of Involuntary movement of hands and head