A 42 YEAR OLD FEMALE WITH LEFT EAR PAIN AND DISCHARGE ALONG WITH SOB

- July 08, 2022

Hi, This is Vijaya Ratna,5th semester medical student .This Elog depicts the patient centered approach to learning. This is an online eLogbook recorded to discuss and comprehend our patient's deidentified health data shared, after taking his/her/guardian's signed informed consent.

A 42 year old female hotel worker by occupation resident of chityal came to OPD with chief complaints of

Shortness of Breath on exertion since 1 month

Generalized weakness since 1 month

Left ear pain since 15 days

HISTORY OF PRESENT ILLNESS

The patient was apparently asymptomatic 5 years back then she developed chest pain suddenly and visited the hospital and joined there for 12 days where all the investigations were done and diagnosed as anemia. So 1PRBC was transferred to her 5 years ago and she used oral iron for 1 year after that. She was normal for 5 years. But again she developed shortness of breath on exertion and generalized weakness 1 month back and had left ear pain since 15 days so she visited a nearby pharmacy and used Ciprofloxacin ear drops upon their advice but wasn't cured. She complained of decreased hearing and mucoid, Non foul smelling discharge from her left ear which was diagnosed as otomycosis.

OTOMYCOSIS IN LEFT EAR

PAST HISTORY

Not a known case of DM, Hypertension ,TB, Epilepsy, seizures ,CAD,CVA.

PERSONAL HISTORY

Appetite - normal

Diet - vegetarian

Takes eggs, dairy products, leafy vegetables twice a week, rice and chapathi with curry.

Regular bowel and bladder movements

Micturition - Burning micturition

Patient wakes up daily at 5am and does her daily routine, goes to work at 6 am as she works in a hotel. She does all works like cleaning tables, sweeping and moping the floor ,cuts vegetables sometimes expect cooking. Returns home in the evening and does her household works and raises her children.

TREATMENT HISTORY

Had Blood transfusion 5 years back and used oral iron for 1 year after blood transfusion.

FAMILY HISTORY

No family history

MENSTRUAL HISTORY

Regular

Moderate flow, no clots.

3 days (uses 3 pads first 2 days and 2 pads last 1 day)

OBSTETRIC HISTORY

She was married at the age of 16. Her first child was born when she was 20 years old which was a normal vaginal delivery but her daughter died within 10 mins after birth. Her second daughter and third daughter were born at the age of 22 and 26 respectively which were caesarean sections.

GENERAL EXAMINATION

Patient was conscious, coherent, cooperative, well oriented to time, place, person and examined in a well lit room.

VITALS

Temperature - 98.6F

Pulse rate - 83/min

Respiratory rate - 18/min

Blood pressure - 96/54mmHg

SpO2 - 98%

GRBS -

PHYSICAL EXAMINATION

Pallor - Present