MEDICINE LOG BOOK BY VANDANAPU SAKETH:
"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardians signed informed consent".
Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
I've 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 clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
01/05/2021
short CASE : A 56-year-old gentleman with easy fatiguability on exertion.
HALL TICKET NUMBER : 1601006192
A 56yr old male , sales manager by occupation , resident of miryalaguda ,came to the OPD with chief complaints of easy fatiguability on exertion since 30 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 30 days back then he developed fatigue on exertion.
The fatigue was insidious in onset , gradually progressed to the present stage.
(He was able to walk 500m initially....
Now he can only walk 100m) which was associated with Dyspnea on exertion , palpitations and body pains.
No complaints of -
chest pain ,
cough ,
fever ,
hematuria .
PAST HISTORY:
No H/o DM , HTN, Asthma, CAD
FAMILY HISTORY:
No significant history
PERSONAL HISTORY:
Diet - Mixed
Appetite - Normal
Sleep - Adequate
B&B - regular
No Addictions
GENERAL EXAMINATION:
Patient was conscious coherent and cooperative
Moderately built and nourished
VITALS:
Pulse - 94 bpm
Regular
Normal volume
BP - 100/70 mm hg
Respiratory rate - 29 cpm
OTHER SIGNS:
Pallor - Present
Icterus - absent
Cyanosis - absent
Clubbing - absent
Koilonychia - Absent
Lymphadenopathy - absent
Edema - absent
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:
S1 S2 Heard
No murmurs
Apex beat heard at left 5th ICS
RESPIRATORY SYSTEM:
Normal Vesicular Breath Sounds
CNS:
All nerves are intact
GIT:
No hepato-spleenomegaly
Bowel sounds heard
DIFFERENTIAL DIAGNOSIS:
Nutritional Anaemia
Iron deficiency anaemia
PROVISIONAL DIAGNOSIS:
Iron deficiency Anaemia.
INVESTIGATION:
-Complete Blood picture
-Stool Examination
-Urine Examination
TREATMENT -
Suggest the patient to go on a diet Rich in Iron
Ferrous Sulphate 200mg OD
Total dose infusion can be done
IM route of ferrous sucrose is also available
In extreme anemia complicated with hemodynamic instability blood transusions can be done.
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