1601006183 SHORT CASE

 

Short case 1601006183


 GENERAL MEDICINE FINAL PRACTICAL CASE:

Short 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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