GENERAL MEDICINE E-LOG

32 CH SRILEKHA, 5th sem

This elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio.

CASE

A 42 year old female, hotel worker by occupation , resident of chityal came to OPD with chief complaints of

1. SOB on exertion since 1month

2. Generalised weakness since 1 month

3. Left ear pain with pus discharge since 1month. 

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 5years ago and then she developed chest pain 5years ago , then she was diagnosed with anaemia. Then 1Pack of RBC was transferred and she was on oral iron tablets for 1year after that. 2years back again she went to one hospital in nalgonda for treatment of anaemia. After that 1month back she developed left ear pain with pus discharge  and loss of hearing and then she used ear drops for 15 days. Then she presented to ENT OPD with ear pain associated with discharge and diagnosed with otomycosis. 

HISTORY OF PAST ILLNESS

History of admission to our hospital in august of 2017 with chest pain and diagnosed with anemia. 

No history of diabetes 

No history of HTN

Not a known case of thyroid 

PERSONAL HISTORY

Marital status : Married 

Occupation : Hotel worker

Diet : vegetarian

Appetite : Normal

Sleep : adequate

Bowel movements : Normal

Micturition : Burning micturition since today morning.

No addictions

She has no known Allergies. 

MENSTRUAL HISTORY : Regular

TREATMENT HISTORY

She was on oral iron tablets  5years back for 1 year , when she was diagnosed with anaemia . 

She used ciprofloxacin ear drops for 15 days when she developed ear pain with pus discharge. 

FAMILY HISTORY

No Significant family history

DRUG HISTORY

Not Significant

GENERAL EXAMINATION

Patient is conscious , coherent , cooperative and examined in a well lit room. 

VITALS

Pulse Rate: 83/min

Blood pressure: 96/54mmHg

Respiratory rate: 18/ min

Temperature : 98.6°F

Spo2 : 98%

PHYSICAL EXAMINATION 

Pallor : present 

Icterus : absent

Cyanosis : absent

Clubbing of fingers and toes : absent 

Lymphadenopathy : absent

Edema : absent

Malnutrition : present

Dehydration : absent

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

S1 and S2 are heard 

No thrills

No murmurs

RESPIRATORY SYSTEM

Dyspnea : present

No wheezing

Trachea : central

BAE +

Vesicular breath sounds : Normal

PER ABDOMEN

Shape : Distended

Tenderness : absent

No palpable mass

Hernial orifices : Normal

No free fluid

No bruits

Bowel sounds : present

CNS 

Conscious

Speech : Normal

No signs of meningeal irritation

Cranial nerves :  intact

Motor system : Normal

Sensory system : Normal

Reflexes : Normal

INVESTIGATIONS

Colour Doppler 2D Echo


X-RAY
HBsAg

Anti HCV-Antibodies
HIV1/2
Dengue NS1 Antigen IgM and IGg
Reticulocyte count

C-Reactive Protein
Hemogram
Blood grouping and Rh type
Blood sugar random
Blood Urea
Complete Urine Examination
LDH

Liver function test
Peripheral smear
Serum Creatinine
Serum electrolytes
T3,T4,TSH 



PROVISIONAL DIAGNOSIS

Anaemia with decreased evaluation (?IDA)

Otomycosis

TREATMENT

T.Cirpofloxacin 500mg PO/BD

T.PAN 40mg PO/OD

CANDID EAR DROPS 3°/3°/3° 5days

T.LEVOCET 5mg

T.BANDY-PLUS (Stat)

Plan 1pRBC transfusion.

FOLLOW UP

1PRBC was transferred yesterday night i.e., on 7/7/2022 but she developed SOB during transfer and PRBC transfer was stopped. 

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