A 22 yer old female was presented to the OPD with generalized weakness and SOB

7th July , 2023 

This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians singned informed consent. Here we discuss our individual patients problems with an aim to solve the patient’s clinical problem with collective current best evident based input.

This E blog also reflects my patient cantered 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 plan.

This is the case of 22 year female degree student , studying in tarnaka , resident of choutuppal 

CHIEF COMPLAINTS :

- generalized weakness since 2 months 

- SOB since 2 months 

- easy fatigability 

HISTORY OF PRESENTING ILLNESS :

 Patient was apparently asymptomatic 2 months ago  , she developed early fatigability and grade 2 SOB , insidious in onset , gradually progressive to grade 3 .

- H/O heavy bleeding in 2017 

- H/O of eating pica , cement 

- no H/O of nausea , chestpain , palpitations, orthopnea , fever , loose stools , vomitings 

PAST HISTORY :

-H/O of similar complaints in 2017

-H/O blood transfusion due to heavy bleeding 

N/K/C/O - HTN , DM , Asthma , Thyroid disorders , antibiotics . 

PERSONAL HISTORY: 

Mixed diet 

Normal appetite 

Adequate sleep 

N/H/O constipation, burning micturition .

N/H/O addictions to alcohol, beetle leaf , smoking , drugs , tobacco 

GENERAL EXAMINATION:

Patient is conscious , coherent and cooperative.

Pateint is examined in a well lit room with

Pallor present 

No clubbing 

VITALS:

Temperature- 98.2°F 

BP-120/70 mmhg

PR- 98bpm

RR-16cpm

No associated pain

SYSTEMIC EXAMINATION:

CVS- S1S2 heard and no murmurs heard.

R/s - bilateral expansion of chest and air entry.

P/a -tender soft

CNS-motor and sensory examination is normal

        - reflexes are elicited