45 year old male with generalised weakness and SOB

 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.

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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 

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