A 54 year old Female with SOB

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Hi, This is Vijaya Ratna,5th sem 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.
**This is an ongoing case.I am in the process of updating and editing this Elog as and when required**

Date of admission : 1/08/2022

A 54yrs old female resident of Nalgonda,occupation by housewife came to OPD with chief complaints of SOB since 2days and generalised weakness.

PRESENT ILLNESS
Patient was apparently asymptomatic 8 months ago then she developed SOB which was insidious in onset and continuous in nature which aggravates on walking and 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. 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.

PAST ILLNESS 
H/O similar complaints in past
She has H/o TB since 6 yrs for which she used ATT drugs for 6 months.
She also has a H/o hyperthyroidism since 4yrs for which she is using carbimazole
She also has H/o arthritis since 4yrs
She is not a k/c/o DM,HTN,asthma,epilepsy
No H/o any allergy to food or drugs

TREATMENT HISTORY:
ATT drugs
Carbimazole

SURGICAL HISTORY:
She had underwent surgery for cleft palate when she was 3yrs old
she also underwent hysterectomy 30yrs back due to heavy bleeding

FAMILY HISTORY
No similar complaints in family

PERSONAL HISTORY:
Appetite:normal
Diet : mixed
Sleep: Adequate
Bowel and bladder movements : regular
Addictions : none

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

GENERAL EXAMINATION
pallor : present
icterus: absent
cyanosis: absent
clubbing : absent
lymphadenopathy:absent
pedal edema: absent 

SYSTEMIC EXAMINATION:  

CVS
S1 and S2 + , no murmurs





CNS
NAD
Per Abdomen
Soft and non tender
Respiratory system
BAE+
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

INVESTIGATIONS
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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