pre final case

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.

Chief Complaints:
A 60 years old female patient resident of Anthampet and a laundry worker by occupation, came on medical OPD on 7-12-2022 with chief complaints of:-
*Shortness of breath, weekness and fatigue since 1 month. 

History of Present Illness:
*Patient is apparently asymptomatic 4years ago , when she started to develop shortness of breath,which was insidious in onset, gradually progressive . 

*H/O Fever , weakness since 1 month. 
*No H/O pedal edema


History of Past illness:
*H/O- Hypertension since 10years on regular medication (using TAB-AMLODIPINE+ATENOLOL  PO/OD)
*PRBC Blood transfusion 2 PRBC 4years ago and 3 PRBC 6months ago
*No H/O-Diabetes, Asthma,TB,CAD, Epilepsy

Personal History:
Diet:Mixed
Appetite:normal
Sleep: inadequate
Bowel and bladder movement: regular

Family History:
No history of Diabetes, Hypertension,TB, Epilepsy,CAD in family members

General Examination:

Patient is conscious, coherent and cooperative.
Moderately built and nourished.

Her consent is taken.
She is examined in a well lit room after adequate exposure.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema.

Vitals:
Temp: Afibrile
Respiratory rate:18cycles/min
Pulse:80bpm
Blood pressure:90/40mmHg
Sp O2 :97%
GRBS:137mg/dl

Systemic Examination:
Cardiovascular Examination:
Inspection: 
- Bilaterally symmetrical chest wall
- Movements - symmetrical
- Skin normal - no scars, sinuses seen.
- Apex impulse not seen.
- No visible pulsations.
- No parasternal heaving seen.
- JVP - not raised.

Palpation: 
- No local rise of temperature and tenderness.
- Bilateral symmetrical chest movement.
- Apex beat - Felt in the left 5 intercostal space -in mmid clavicular line.
- Parasternal heave - absent.
- No visible pulsations.

Percussion:
- Right heart border - about 1cm to right of sternum.
- Left heart border - about 2cm lateral to mid clavicular line.

Auscultation:
- S1 and S2 heard 
- murmur - absent


Respiratory system:
Position of trachea: Central
Breath sounds:No
Adventitious sounds:No

Abdomen
Shape of abdomen: Scaphoid
Tenderness:No
Palpable mass:No 
Henias orifices: Normal
Free fluid:No

Central Nervous system:
 Pt is conscious
Speech:Normal
Signs of meningitis:No 
Cranial nerves: Normal
Motor and sensory system: Normal

Investigation:
provisional diagnosis:
IDA. 

Treatment:
RX:-
Inj.IRON SUCROSE 200Mg in 100ml of NS   OD/IV(alternate days)
Tab.AMLONG AT    PO/OD(1-0-0)
Monitor vitals 6hourly

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