A 25yr old female came with chief complaints of SOB Grade II - III since 6 months

 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 reflects my patient centered online portfolio and your valuable inputs on the comments is welcome

Name :- P. Sai Krupa Sri (intern) 
Roll no:- 113 

Date :- 31/5/23 

A 25yr old female came with chief complaints of SOB Grade II - III  since 6 months 

History of present illness :- 

Patient was apparently asymptomatic until 2016 then developed headache, occipital region more, insidious in onset , gradually progressive, prominent with nausea and occasional vomitings, associated with photophobia, phonophobia, no lacrimation , no aggravating factors and relieved with medication.
She also had difficulty in writing ( associated with pain at tips ) and on investigation was found to have low hemoglobin (also had SOB, grade I - III ) jaundice and so, reports - Hb electrophoresis S/o HbE and mild iron deficiency anemia and was treated accordingly
In dec 2022 , patient had right hypochondric region pain , and on USG abdomen --> gallstones present and was operated for it.
Laproscopy cholecystectomy done.
In Feb 2022, patient experienced polyphagia, polydyspsia , nocturia present (3-4 times) and went for dental checkup , and on investigation , was found to have high sugars and was diagnosed to have diabetes, and since then she was on regular medication, presently using Tab.Lipoglobin HP BD and Tab. Vildamne 50 2 tabs (night).
Now SOB grade II - III increased since 6 months 

Past history :- 
Known case of diabetes mellitus since 1yr on medication Tab.Lipoglobin HP BD and Tab. Vildamne 50 2 tabs (night).
Not a known case of thyroid disorders , HTN , asthma 
No chest pain and no orthopnea 

Personal history:- 

Diet- eggtarian 
Appetite - decreased
Sleep - adequate 
Bowel and bladder- regular 
No allergies 
Addiction - teetotaler 
Tobacco - snuff 

Family history:- 

Grand father has diabetes mellitus II 

Menstrual history:- 

Aom- 13yrs 
Menstrual cycle - 7/30-35days 

General examination:- 

Patient is conscious, coherent, co operative 

Pallor present 
No icterus, cyanosis, clubbing, lympadenopathy , edema 

Vitals:- 

Temp:- 98f 
Pr- 96bpm 
Rr- 16cpm 
Bp- 120/80mm hg 
Spo2- 96% 
Grbs- 309 mg/dl 

Systemic examination:- 

Cvs- S1S2 heard , no murmurs 
Rs- BAE present , NVBS present 
P/A - soft , non tender 
CNS- NAD 











Investigation:- 
FBS- 191mg/dl 
PLBs:- 241mg/dl
HBA1C : 6.7 
HEMOGLOBIN:- 6gm/dl 
 TLC- 7,800
 PLT- 92,000

Provisional diagnosis:- 

Metabolic syndrome with diabetes HbE thalassemia 


Treatment:- 

 Tab.Lipoglobin HP BD 
 Tab. Vildamne 50 
Tab. GLIMIPERIDE 0.5mg PO/BD 
Tab. Metformin 1000mg PO/OD 
Tab.folic acid 5mg PO/BD
Tab. Orofer XT PO/OD




Discharge summary













Comments

Post a Comment

Popular posts from this blog

A 85 yr old female with weakness of right upper limb and lower limb

Image
  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 reflects my patient centered online portfolio and your valuable inputs on the comments is welcome Name :- P. Sai Krupa Sri  Roll no :- 175  A 85 yr old female with weakness of right upper limb and lower limb Chief complaints :  •Right sided weakness of hand and leg since 1 day History of present illness :  •Patient was apparently asymptomatic 1 day back  •later she developed weakness of right sided upper and lower limb which is sudden in onset associated with deviation of mouth to the left , head fixed to left side. •No History of seizures and no History of loss of cons...
Read more

INTERNSHIP ASSESSMENT

 INTERNSHIP ASSESSMENT  NAME:- P. SAI KRUPA SRI  ROLL NO :- 113  INTERN  I HAVE BEEN POSTED IN GENERAL MEDICINE FROM 14/4/23  TO  12/6/23  IN THIS BLOG I WOULD LIKE TO SHARE MY EXPERIENCE  IN GENERAL MEDICINE.   1st 15 DAYS => UNIT DUTIES (14/04/23 - 28/04/23)  NEXT 15 DAYS => PERIPHERALS (29/04/23 - 13/04/23)  NEXT 15 DAYS => PSYCHIATRY ( 14/05/23 - 28/05/23) LAST 15 DAYS => UNIT DUTIES (29/05/23 - 12/06/23) UNIT DUTY:-  1.I have drawn venous blood samples 2. Collected their reports from the labs, 3. Got culture swabs and bottles from the labs 4. Collected culture reports from the lab  5.Updated these in our whatsapp groups, investigation charts, fever charts, repeats 6. Got ECGs, Xrays, USGs, 2D echos and their videos of all our patients 7. Monitored vitals of all our patients 8. Typed and printed discharge summaries of all our patients ON OP DAYS :-  1. I have done vital monitoring of the patients...
Read more

A 20 yrs female with abdominal pain and vomiting

Image
  This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome.  Name: P. Sai Krupa Sri Roll no: 175  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 comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan. CASE PRESENTATION : A 20 yr old female, student by occupation has come to the OPD on 22nd march 2022 with the chief complaints of Abdominal pa...
Read more