40f with palpitations and sob

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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.

A 40 year old female patient ,hotel owner, resident of Narketpalli came with chief complaints of…

Increased heartbeat since 6 months

Breathlessness since 6 months

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 6 months back then she developed palpitations which were sudden onset, gradually progressive and develops under stress, heavy work.

It lasts for 2 to 3 min and relives on rest .

Since the last 2 to 3 months she complains of increased frequency and intensity of palpitations.

She also complains of breathlessness ( shortness of breath) since 6 months and it was gradually progressive from grade 1 (6 months back)to 3 (presently)and it relieves on rest.

Patient also has hypoglycaemic attacks , headache when there is delay in food intake or prolonged standing and it gets relieved on taking rest or food.

PAST HISTORY

Not a known case of Diabetes, Hypertension, Asthma, Tuberculosis,Epilepsy, Thyroid disorders.

Has acidity from past 15 years.

She develops burning sensation in abdomen when she consumes oily food, spicy foods ,chapathi.

And for this she takes pantropazole every morning half n hr before food.

No history of prolonged hospital stay or surgeries.

She had sore throat 2 months back for which she consulted Local practitioner and was given some IV medication and was asked to get thyroid function test and complete blood picture done. Her thyroid profile was normal but her HB was 5.5 gm/dl.(anemic)

The local practitioner gave some oral medications for anemia but she neglected it .

TREATMENT HISTORY
Using pantop since 15 years every day morning 

FAMILY HISTORY

No relevant family history

MENSTRUAL HISTORY

Menarche at 13 years

Regular cycle , 3/28

Uses 2 pads/day

Not associated with clots

No pain

Has premenstrual symptoms like back pain, leg pain

PERSONAL HISTORY 

DAILY ROUTINE

She wakes up at 6.30 am

Does her morning routine

Does household work( sweeping, cleaning dishes,cooking)

Breakfast at 8.30 am

At 9 am she starts preparing items for hotel food, cleans the hotel 

Lunch at 2 pm

Tea at 5pm

Dinner at 9 pm 

Until then she does hotel work ( cutting vegetables, serves people, cleans hotel, cleans dishes)

Returns to home by 10 or 11 pm 

Sleeps by 11 pm

Diet -vegetarian

Appetite- normal

Bowel and bladder movements-regular

Sleep-adequate 

Addictions- none

Allergies -none

GENERAL EXAMINATION 

Patient was conscious,coherent, cooperative 

Built and nourishment- poor 

Well oriented to time, place ,person

height- 5.2 inch

Weight-44 kg

BMI- 17.7

Pallor - present

Icterus- absent

Cyanosis -absent

Clubbing-absent

Lymphadenopathy -absent

Edema-absent

VITALS

Temperature -a febrile

BP- 130/90 mmHg
RR- 16cpm

PR- 84bpm

SYSTEMIC EXAMINATION

ABDOMINAL EXAMINATION 

Inspection : 

Abdomen flat

Moves with respiration

no abdominal distension

umbilicus is central and  inverted 

no engorged veins

no scars,sinuses,

hernial ornifices are clear

Palpation

   All inspectory findings are confirmed

    No tenderness

Percussion

    No significant findings 

    

Auscultation 

    Bowel sounds heard

    No bruits

RESPIRATORY EXAMINATION 

Normal vesicular breath sounds

Trachea central

CARDIOVASCULAR SYSTEM

S1S2 heard

No murmurs

CENTRAL NERVOUS SYSTEM

No focal neurological deficits 

INVESTIGATIONS

PROVISIONAL DIAGNOSIS

Dimorphic anemia 

Secondary to nutritional cause

IDA?

TREATMENT 

On 29/11/22

Inj Vitcofol 1.5gm IV OD in 100 ml NS

Tab albendazole 400 mg PO OD

Tab Lirogen PO OD every alternate day

Tab esomeprazole 20mg PO OD (7am)

Vitals monitoring every 6th hrly 

On 30/11/22

Inj Vitcofol 1.5gm IV OD in 100 ml NS

Tab Lirogen PO OD every alternate day

Tab esomeprazole 20mg PO OD (7am)

Vitals monitoring every 6th hrly