45 years old female with shortness of breath

 January 06,2023.

This is an online E-log book to discuss our patients deidentified health data shared after taking his or 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 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 year old female patient presented to the opd with chief complaints of shortness of breath from 15 days who is a house maker by occupation 

HISTORY OF PRESENT 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 and cold temperature(class 2 NYHA) and relieved on rest. Within few days of onset of her symptoms the shortness of breath has progressed to class 4 NYHA which is shortness of breath at rest. So she went to a local hospital where she took a blood test and found her hemoglobin levels to be very low(3.6gm/dl) and she was referred to our hospital for blood transfusion

H/O cough since 15 days which is associated with mucous which is yellowish white in color and intermittent in nature

No history of any bleedings, weight loss, burning micturition, vomitings, loss of sensation and change in appetite, chest pain, GI bleeding.

No history of weight changes

Past history:-

Previous history of menorrhagia diagnosed having fibroids in uterus.

No history 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-

I have examined the patient in a well lit room with a female nurse ,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 - Bilateral on lower limbs till knees pitting type 

VITALS-

Temperature afebrile

Respiratory rate 30cpm

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-

06/01/22 no test reports

05/01/22

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 ecospril

Tab carvediol 

Inj Vitcofol

Tab orofer