GEN MED E LOG 11 AUG

 E-LOG GENERAL MEDICINE

Hi, This is easha chandrika, a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them.

A 40 YRS OLD WITH SEVERE ANEMIA AND GENERAL WEAKNESS 

Chief complaints:

A 40 year old female hailed from valigonda presented to the causality with chief complaints of

Heavy bleeding during periods since 2yrs

Diminished vision since 1yr

General weakness since 3 months 

Headache since 3 month 

HISTORY OF PRESENTING ILLNESS: 

The patient was apparently asymptomatic 2 years back and then she had

• heavy menstrual bleeding and prolonged duration of period for 7days for every 28days of cycle

( previously it was 3days for every 28days of cycle ), with no h/o passage of clots

• diminished vision for past 1year,

•then developed Generalised weakness and easy fatigability from 3 months 

•headche from 3 months of frontal site subsided on medication. 


HISTORY OF PAST ILLNESS:

N/k/o HTN,DM,TB,epilepsy,asthma,thyroid.


TREATMENT HISTORY:

NIL


PERSONAL HISTORY:

Married

Occupation: vender in chicken shop

Diet: Mixed , Non vegetarian 

Appetite: decreased 

Sleep: inadequate 

Bowels: Regular 

Known Allergies: No

No addictions.


FAMILY HISTORY:

Not significant 


MENSTRUAL HISTORY:

Age of menarche-15yrs

Menstrual cycle- past:3/28, present :7to8/28

LMP-20/7/22


OBSTETRICS HISTORY:

Age of marriage-18yrs

Para-P2L2

No of live births-2

No abortions


BIRTH HISTORY 

full term normal delivery 

IMMUNIZATION STATUS:up to mark


GENERAL EXAMINATION

Patient is conscious and coherent

Moderate built and moderately nourished

Well oriented to time, place and person. pallor present 


 

 NoIcterus 

No cyanosis 

No clubbing 

No lymphadenopathy

Oedema of feet -no

No malnutrition 

No dehydration 

VITALS:

Temperature-afebrile

Pulse rate- 82/min

Respiratory rate- 16/min

BP- 120/80mmHg

SPO2 - 98% 

GRBS- 120mg%

SYSTEMIC EXAMINATION


CARDIOVASCULAR SYSTEM

Thrills: No

Cardiac sounds: S1 , S2

Cardiac murmurs: No


RESPIRATORY SYSTEM

Dyspnoea:No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

Adventitious sounds : No

ABDOMEN

Shape - Scaphoid 

No tenderness, palpable mass, 

No Fluid 

No bruits

CENTRAL NERVOUS SYSTEM

Level of consciousness - consciouss

Speech - Normal

No signs of meningeal irritation

Cranial nerves - Normal

No motor or sensory deficit

Reflexes 

        Biceps Triceps Supinator Knee Ankle  

Right + + + + +           

Left + + + + +

INVESTIGATIONS:


 PROVISIONAL DIAGNOSIS :
Intramural fibroids
TREATMENT:







 


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