This is an a 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.
CASE:
A 55 year old female patient who is a homemaker resident of munugodu came to tge opd with the chief complaints of generalised weakness, fever and shortness of breath since 3 days.
History of presenting illness:
Patient was apparently asymptomatic 3 years back then she had joint pains and went to a local hospital and incidentally found to have hyperthyroidism and was on medication (carbimazole). Last year in December she had fever sob malaise and fell unconscious and taken to a local hospital and found to have hemoglobin of 3gm% and was transfused with 1 unit of blood and hb increased to 8 gm%. Since then she has been having fever every week that is intermittent and subsided on medication (paracetamol). On July 5th she went to the hospital for sob and her hb fell to 3gm% and got 2 units of blood transfused and hb increased to 7gm% . She has had cough since 15 days(non productive). 3 days back she had fever,sob even on rest(Grade 4) and she couldn't sleep and was sitting on bed day before yesterday because of shortness of breath and taken to local hospital given Fluids iv and was referred here. Hb was 3.8gm%. Now she has sob of grade 3. Yesterday night 1 unit of blood was infused.
No history of bleeding per rectum or per vagina.
Past history:
Patient is a known case of Tuberculosis 6years back and used Anti Tuberculosis therapy for 6 months.
She is also a known case of hyperthyroidism and is on medication (carbimazole).
She is not a known case of Hypertension,diabetes,Asthma,epilepsy,CAD.
She underwent Hysterectomy 30years back(because of irregular and heavy bleeding).
She had surgery for cleft lip at the age of 3years.
Personal history:
Diet-mixed
Appetite-normal
Sleep-adequate
Bowel and bladder movements-regular
Addictons-none (drink Toddy once in 6 months)
Family history: not significant
Treatment history:
She is on carbimazole for hyperthyroidismfrom 3 years; Ibuprofen for joint pains since 3days.
General examination:
Patient is conscious coherant cooperative
She is well oriented to time place and person.
She is poorly built and undernourished.
Pallor-present
Icterus-absent
Cyanosis-absent
Clubbing-abesnt
Lymphadenopathy-absent
Pedal edema-absent
Fine tremors-present.
Vitals:
Temp-98.6 degree F
Pulse rate-86bpm
Respiratory rate-22cpm
Blood pressure-120/70mmhg
Spo2-97% at room air.
Grbs-106mg/dl
Systemic examination:
Cardiovascular system: S1 and S2 heard and no murmurs heard. There are engorged neck veins (Raised JVP).
Respiratory system: Bilateral air entry-present, normal vesicular breath sounds-heard, no adventitious sounds heard.
Abdomen: soft and non tender. There is a surgical scar for Hysterectomy. No Hepatomegaly and spleen is not palpable.
Central nervous system: No focal neurological deficit and cranial nerve intact.
Skeletal system: swollen ankle and wrist joints.
Provisional diagnosis:
Anemia with chronic inflammation and Renal failure
Investigations:
On 1-8-2022(before transfusion of blood)
LFT:
Thyroid function test:
CUE:
On 2-8- 2022(after blood transfusion):
ECG:
2d echo:
Treatment :
Tab. OROFER XT OD
IV NS@30ml/hr
Inj. VITAMIN B12 im OD
1pack PRBC transfusion.
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