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
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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