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
Chief complaints
A 22 yr old female who is a student came with complaints of generalized weakness and easy fatiguability since 2 months
History of present illness
Patient was appearently asymptomatic 2 months back
Then developed easy fatigubility, generalised weakness
- Case of - SOB grade 2/3, incidious in onset, gradually progressive to grade 3
- exertional dyspnoea
History of past illness
H/o similar complaints in the past 5 years back
History of blood transfusion (PRBC) - no reaction
N/K/C/O - Hypertension,DM, Asthma, Thyroid disorder
Personal History
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel: regular
Micturition: normal
Addictions: No
Allergies: nil
Family history
No significant family history
Daily routine
Patient wakes up around 7 am and takes a breakfast and go to the coaching classes have lunch in the afternoon and come back to home at 6 pm and have dinner at 8 pm and sleeps at 10 pm
Her daily routine did not change even after the weakness
General examination
Pallor present
No Icterus
No clubbing of finger
No cynosis
No Lymphadenopathy
pedal edema present
Vitals
Temperature - afebrile
Pulse - 96
Respiration rate - 16/min
BP - 110/80 mmhg
Systemic Examination
CNS EXAMINATION:
GCS: 15/15
The patient is conscious.
Speech: normal
Cranial nerves: intact
Seonsory system: normal
Motor system:
UL LL
Tone R INCREASED INCREASED
L INCREASED INCREASED
POWER
R 5/5 5/5
L 5/5 5/5
REFLEXES R L
BICEPS 2+ 2+
TRICEPS 1+ 1+
SUPINATOR 0 0
KNEE 0 0
ANKLE 0 0
PLANTAR E E
RESPIRATORY SYSTEM EXAMINATION
-Bilateral air entry is present, normal vesicular breath sounds heard.
CARDIO VASCULAR SYSTEM
S1 and S2 are heard. No murmurs are heard
ABDOMINAL EXAMINATION:
Soft, non-tender.
No organomegaly
Bowel sounds are normal
Investigations
Diagnosis
Iron deficiency Anemia
Blood Transfusion
08/07/23 - Hb 7.6
10/07/23 - Hb 8.9
