A 35 year old female came with the headache,neck pain, generalised weakness since 3 days

This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.


Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.


This E-blog also reflects my patient's centred online learning portfolio.

Chief complaints:

A 35 year old female came with the

 -complaints of neck pain  and head ache since 3 days

-complaints of genralised weakness, giddiness since 3 days 

-complaints of shortness of breath on and off since 3 days 

HOPI:

Patient is fine since 10 years now she is complaining of neck pain ,headache since 3 days and associated with generalised weakness ,giddiness since 3 days patient is feeling breathless- having breathless episodes and is then waiting up from sleep, subsides in 3 to 5 minutes, SOB on walking grade 2 on and off since 3 days, outside HB 5.0gm/dl was referred to our hospital .

No complaints of any bleeding manifestations.

 Now no complaints of fever menorrhagia, tingling of limbs ,vomitings loose stools.

Non DM,HTN,thyroid disorder.

Past history:

17 years ago history of menorrhagia for 1 month - Hb-3mg/dl, 5. PRBC transferred.

15 years ago birth of male child, no complications 

13 years ago ?septic abortion, 2.PRBC transferred i/v/o anemia 

10 years ago during pregnancy was transfused with iron injections -birth of female child (after 4 years child died with febrile seizures)

Diet-leafy vegetables rarely once in a month or 2 months ,non veg rarey chicken ,fish .eats mutton once a week or once two weeks, eats vegetables daily 

GENERAL EXAMINATION:

Temperature 98.6 F 

Pulse-63bpmRR:18cpm

BP-120/70mm Hg 

Spo2-98% @RA 

No pigmented knuckles

SYSTEMATIC EXAMINATION:

PER ABDOMEN:Soft, non tender

No guarding, No rigidity 

Bowel sounds present 

CARDIOVASCULAR SYSTEM:

S1,S2 heard, NO Murmurs 

RESPIRATORY SYSTEM:

   BAE present,NVBS

CENTRAL NERVOUS SYSTEM:NAD



INVESTIGATIONS:

Blood group

Hemogram

Peripheral smear
CUE

LFT

serum electrolytes

Blood urea

serum creatinine

Serum iron

Serum ferritin

ECG


2d echo
Hemogram (18/5/22)

Hemagram(19/5/22).                                         



DIAGNOSIS: anaemia under evaluation ?IDA


Plan of treatment

1. Plan 1.PRBC

2.Tab.OROFER PO OD

SOAP NOTES 


18/5/22

SOAP NOTES (AMC)

S-  HEAD ACHE,NECK PAIN, GENERALISED WEAKNESS


O- PATIENT IS CONCIOUS,COHERENT,COOPERATIVE. 

 PALLOR PRESENT ,NO ICTERUS ,CLUBBING,CYANOSIS,LYMPHADENOPATHY.


VITALS-

TEMPERATURE - 98.2F 

PULSE RATE-92bpm 

BLOOD PRESSURE - 110/ 80 mm hg

SPO2 - 98% AT RA


On 

SYSTEMIC EXAMINATION - 

PER ABDOMEN : SOFT NON-TENDER,NO GAURDING/RIGIDITY

CVS : S1 S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT,NORMAL VESICULAR BREATH SOUNDS

CNS : NAD

A -  ANEMIA UNDER EVALUATION ? IDA

P - 

1)Tab.OROFER PO OD

2) 1. PRBC TRANSFUSION DONE



19/5/22

SOAP NOTES (AMC)

S-  HEAD ACHE,NECK PAIN, GENERALISED WEAKNESS


O- PATIENT IS CONCIOUS,COHERENT,COOPERATIVE. 

 PALLOR PRESENT ,NO ICTERUS ,CLUBBING,CYANOSIS,LYMPHADENOPATHY.


VITALS-

TEMPERATURE - 98.2F 

PULSE RATE-90bpm 

BLOOD PRESSURE - 100/ 60 mm hg

SPO2 - 98% AT RA


On 

SYSTEMIC EXAMINATION - 

PER ABDOMEN : SOFT NON-TENDER,NO GAURDING/RIGIDITY

CVS : S1 S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT,NORMAL VESICULAR BREATH SOUNDS

CNS : NAD

A -  ANEMIA UNDER EVALUATION ? IDA

P - 

1)Tab.OROFER PO OD

2) Tab.BANDY PLUS PO/OD/HS

Planning for discharge













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