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
Post a Comment