1601006084 SHORT CASE

1601006084 ( Short CASE)

GENERAL MEDICINE FINAL PRACTICAL 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. 


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

CASE

A 56yr old male , sales manager by occupation , resident of miryalaguda ,came to the opd with cheif complaints of easy fatiguability on excertion since 30 days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 30 days back then he developed fatigue on excertion which was insidious in onset , gradually progressed to the present stage. ( He was able to walk 500m initially.... But now he can only walk 100m ) which was associated with Dyspnea on excertion , palpitations and body pains.

No complaints of - chest pain , cough , fever , hematuria .

PAST HISTORY

No H/o DM , HTN, Asthma, Epilepsy, 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 

Moderatly 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 

Cynosis - 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 hepatospleenomegaly
Bowel sounds heard

Differential Diagnosis

Nutritional Anemia
Iron deficiency anemia

Provisional Diagnosis

Iron deficiency Anemia


INVESTIGATIONS

-Complete Blood picture
-Stool Examination ( occult blood )
-Urine Examination











Treatment - Diet Rich in Iron
                        Ferrous Sulphate 200mg OD
                     

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