45 years old with shortness of breath

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 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. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment .





A 45 yr old female home maker by occupation presented to opd with chief complaints of shortness of breath since 15 days.


HISTORY OF PRESENTING ILLNESS- 


Patient was apparently asymptomatic 15 days ago . Then she developed shortness of breath which was insidious in onset gradually progressive and aggravated on stress, work and cold temperatures (Class ll NYHA ) and relieved on rest.Within to few days of onset of her shortness of breath it progressed to even at rest   ( Class lV) so she went to local hospital were her haemoglobin levels were found to be low (3.6gm/dl) and she was advised to our hospital for blood transfusion.

History of cough since 15 days which is mucus asssociated yellowish white in colour intermittent in nature

No history of any bleeding, weight loss, burning micturation, vomitings, loss of sensations and change in appetite, chest pain, GI bleeding. 

No history of any weight changes


PAST HISTORY-

 Previous history of menorrhagia diagnosed having fibroids in uterus.

Not a known case of hypertension, epilepsy, asthma, coronary artery disease or chronic kidney disease.


PERSONAL HISTORY-

Diet is Mixed

Appetite is normal

Bladder and bowel are movements regular

Sleep is adequate

No Allergies

No Addictions 


FAMILY HISTORY-

Not significant 


MENSTRUAL HISTORY-

Age of menarche 12 yrs

Previous cycles were 3/30 with no pain and clots

Since 1 yr she is having 5/20 with heavy menstrual bleeding with no pains and clots and she went to hospital and was diagnosed with fibroids and was advised hysterectomy and then on routine investigations because of her low hb surgery was postponed and she was given blood transfusions and her hb raised to 8 gm% which was not adequate for surgery and as she qas approaching menopause on advise of her relatives she didnt want surgery 



DRUG HISTORY-

She had a previous blood transfusion of 3 packs 1 yr back

Medroxy progestrone acetate once daily for 2 months

Dexorange from last 4 days


SURGICAL HISTORY-

She had previous two LSCS and tubectomy done.


GENERAL EXAMINATION-

Patient is conscious coherent and co operative well oriented to time place and person. 

She's moderately built and nourished.




Pallor - Present




Icterus - Absent

Clubbing- Absent

Cyanosis- Absent

Lymphadenopathy- Absent


Edema - B/l on both lower limbs till knees pitting type 




VITALS-

Temperature afebrile

Respiratory rate 18cpm

Pulse rate 118bpm

Blood pressure 110/70mmHg

Spo2 97%


SYSTEMIC EXAMINATION-


CVS- S1 S2 heard No murmurs JVP raised 



RS- Normal vesicular breath sounds

P/A- Soft non tender no organomegaly C section scar visible.

CNS - No focal neurological deficit.


PROVISIONAL DIAGNOSIS-

Anemia leading to secondary right heart failure


INVESTIGATIONS-

4/1/23





Previous





PROBABLE DIAGNOSIS-

Dimorphic anemia with Heart failure.


TREATMENT-


Fluid restriction < 1.5 lit/day

1 pack of PRBC was done after injecting lasix 20mg



Inj lasix

Inj escoripin

Tab carvediol 

Inj Vitcofol

Tab orofer 

I/O charting




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