gm blog 18/04/2023 of a 29yr old female patient

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 comments on comment box is welcome.

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 prognosis
A 29 yr old female residence of gurrampudu nalgonda district came with
Cheif complaint: she came to gynaecology OPD 4days ago for tubectomy and diagnosed with severe anemia and reffered to general medicine
She had fever 2days ago and complaints of weakness 
History of presenting illness:
Patient was apparently asymptomatic 2 days ago and then developed fever which is sudden in onset,low grade And intermittent type  not associated with chills and rigors relieved on medication and no aggravating factors present.
She had generalised weakness since 2 days while doing daily routine works.
H/o bleeding for 7 days last month without clots and normal flow.
No H/o pain abdomen,
No H/O cough,cold and headache
No H/O burning micturition 
No H/O weight loss,loss of appetite.
No H/o blood in stools,melena 
Menstural history:
Age of menarche: 15 years
Regular cycle of 30 days with 5days bleeding till February
Last month she had bleeding for 7 days with normal flow without clots 
Past history: 
She is not a known case of diabetes, hypertension, tuberculosis,asthma,epilepsy and thyroid disorders.
No h/o medication
No h/o blood transfusions 
H/o of 2 cesarian sections 
Family history: not significant
Personal history: 
Diet: mixed
Appetite: decreased
Sleep: adequate
Bowel and bladder movements: regular
Addictions: none 
General examination
Patient is conscious, coherent and we'll oriented to place and time 
Thinly built and malnourished
Pallor - present 
icterus- absent
Cyanosis-absent
Clubbing- Absent
Koilonychia- absent
Lymphadenopathy - absent
Oedema - absent
Vitals 
Temperature- febrile on touch
Blood pressure- 110/70
Pulse Rate-80 BPM
Respiratory rate- 20 cpm

Systemic examination
CVS EXAMINATION:
Inspection : 
Shape of chest- elliptical 
No engorged veins, scars present
Trachea position central
Jvp- normal
Apical impulse- present


Palpation :
Trachea - central
 Apex beat can be palpable in 5th inter costal space
No thrills and parasternal heaves can be felt
Percussion:
       All boarders of heart are felt.
Auscultation : 
S1,S2 are heard
no murmurs 
Investigations 
Provisional diagnosis: iron deficiency anemia
TREATMENT:
     10 PRCB transfusion 
      Tab dolo 650mg  
      Tab.ferrous ascorbate+folic acid




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