GENERAL MEDICINE E-LOG
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Date of admission : 01/08/2022
CASE
CHIEF COMPLAINTS:
A 54yrs old female who is a housewife ,resident of Nalgonda came to opd with chief complaints of SOB since 2days and generalised weakness.
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 8 months ago then she developed SOB which is insidious in onset and continuous in nature which aggravates on walking and also on lying down.It gets relieved on sitting position [grade 3 SOB].It is also associated with dry cough.She also has genearalised weakness and also fever since 8months which is intermittent in nature.
She consulted a local doctor in Nalgonda from where she got to know that she has low Hb levels for which she underwent blood transfusion and again back in July her Hb levels were found low[5.0g/dl] and again she underwent blood transfusion[2units] after which her Hb levels increased from 5.0 -8.0g/dl.She again developed SOB and generalised weakness since 2days for which she again consulted a local doctor in Nalgonda and got her tests done. Now her Hb levels have got down within a month that is around 3.8g/dl.So she came here for blood transfusion.
HISTORY OF PAST ILLNESS
H/O similar complaints in past
Known case of TB since 6 yrs for which she used ATT drugs
Known case of hyperthyroidism since 4yrs for which she used carbimazole
She also has h/o arthritis since 4yrs
Not a k/c/o DM,HTN,asthma,epilepsy.
TREATMENT HISTORY:
ATT drugs
Carbimazole
SURGICAL HISTORY:
She had underwent surgery for cleft palate when she was 3yrs old
she also had underwent hysterectomy 30yrs back due to heavy bleeding
FAMILY HISTORY:
No significant family history
PERSONAL HISTORY:
Appetite:normal
Diet : mixed
Sleep: Adequate
Bowel and bladder movements : regular
Addictions : none
She has no known allergies
GENERAL EXAMINATION:
Patient is conscious , coherent , cooperative and well oriented to date , time and place
Patient is ill built and undernourished
VITALS
BP: 120/70 mm hg
PR: 70 bpm
RR: 20cpm
temperature: 98.6*F
SPO2: 95%
GRBS: 106mg/dl
PHYSICAL EXAMINATION
pallor : present
Icterus: absent
cyanosis: absent
clubbing : absent
lymphadenopathy:absent
pedal edema: absent
SYSTEMIC EXAMINATION:
CVS
S1 and S2 are heard
No thrills
No murmurs
RESPIRATORY SYSTEM
INSPECTION:
Tracheal position is central
Symmetrical chest
PALPATION:
All inspectory findings are confirmed by palpation
Trachea is central
Chest is symmetrical with
AP diameter : transverse diameter =5:7
Symmetrical expansion of chest
Vocal fremitus is felt
PERCUSSION:
Resonant on percussion
AUSCULTATION:
Breath sounds are 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
ECG
Color Doppler 2D Echo
- PROVISIONAL DIAGNOSIS
- Chronic inflammatory anaemia
TREATMENT
02/08/2022
Normal Diet
IVF-NS J @30ml/hr
Inj.Lasix 20mg /IV/BD
Tab. Orofer -XT /PO/OD
I/O charting
Vital monitoring
Inj. Vit-B12 1500micro gm /Im/ OD
Tab. Moximac 600mg po/OD
Neb. Salbutamol /1resp/stat
03/08/2022
Normal Diet
IVF-NS J @30ml/hr
Inj.Lasix 20mg /IV/BD
Tab. Orofer -XT /PO/OD
Neb with Mucomyst /2Rsp
Neb with salbutamol /1Resp /BD
I/O charting
Monitor vitals and fever charting
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