case no 8
A 22Year female with fatigue and generalized weakness
Hi,I am Arundathi 5th semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio.
CASE SHEET
CHIEF COMPLAINTS:
A 22 year female patient came to the OPD with chief complaints of
Easy fatiguability since 2 months
Generalized weakness since 2 months
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 months back then she developed easy
fatiguability and generalized weakness
C/o SOB grade II,III which is incidious in onset gradually progressive to grade III
No history of chest pain, palpitation,orthopnea
No cause of fever , diarrhoea, vomiting
PAST HISTORY:
No diabetes
No hypertension
No CAD
No asthma
No tuberculosis
No epilepsy
History of similar complaints in the past
History of blood transfusion in the past
PERSONAL HISTORY:
Unmarried
Appetite - normal
Diet - mixed
Bowl movement - regular
Sleep- normal
No allergies
No addictions
FAMILIES HISTORY:
Not significant
MENSTRUAL HISTORY:
Age of menarche :14years
Menstrual cycle: duration of cycle/no of days bleeding =5/28
GENERAL EXAMINATION:
Pt was conscious, coherent and cooperative
Moderately built and nourished
Pallor- present
Icterus- Absent
Cyanosis- Absent
Clubbing- Absent
Lymphadenopathy- Absent
Pedal oedema- Absent
Vitals:
Temperature : 98.6F
Pulse rate : 98/min
Respiratory rate : 16 per minute
Blood pressure : 110/70 mm of Hg
sPO2 : 98%
Systemic Examination
Cardiovascular System-
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System
no dyspnea
No wheezing
central trachea
vesicular breath sounds
Adventitious sounds-rhonchi
Abdomen
Scaphoid shaped abdomen
No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds -yes
CNS
Patient was conscious
Normal speech
Reflexs
Right. Left
Biceps. +2. +2
Triceps. +1. +1
Supinator. +1. +1
Knee. +2. +2
Ankle. +1. +1
INVESTIGATIONS:
