General medicine internal assignment

 

45 year-old male with generalised weakness

 

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have 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 comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 45 year old male from Miryalaguda, farmer by occupation came to the OPD with complaints of •generalised weakness 

•mild shortness of breath since 5 months. 

HOPI- 

•Patient was apparently asymptomatic 5 months back, then he developed fatigue and weakness on continued exertion.

• Two episodes of blood loss while passing stools, 6 months back. 

•h/o shortness of breath since 5 months, not associated with palpitations, orthopnea, pnd. 

Past History-

Not a known case of DM, HTN, asthma, TB, CVD, epilepsy 

Personal History-

Diet: Mixed (more vegetables than meat, and fish)

Appetite: Adequate 

Sleep: disturbed sleep due to leg pain 

Bowel and bladder: normal 

Addictions: Smoking since 25 years (10/day)

Allergies: None 

Family History- 

Not relevant 

Treatment History- 

Not significant 

->GENERAL EXAMINATION:

Patient is examined in a well lit room after taking informed consent. 

Patient is conscious, coherent and cooperative, well oriented to time and place. 

Pallor: present

Icterus: absent 

Clubbing: absent 

Koilonychia: absent 

Lymphadenopathy: absent 

Pedal edema: absent 

Vitals 

PR: 96bpm

BP: 110/60

->SYSTEMIC EXAMMINATION: 

CVS : S1,S2 +, No added sounds.

R/S : BAE+, Clear.

P/A : Soft, Non tender, No organomegaly.

CNS: NFND

Investigations:

Provisional Diagnosis: 

Microcytic hypochromic anemia secondary to two episodes of blood loss.

Treatment: 

Blood transfusion on day of admission 

10 PRBC on 18/7/23

Pantop 40mg

OROFER XT 

NEUROBION FORTE 

INJ VITCOFOL