GENERAL MEDICINE ELOG.

Hi,I am Mattupalli Pritish Jasper 3rd semester medical student.This is an online e block to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio

A 35 year old female came to OP with fever and weakness 


Chief complaints:

The patient complained of severe breathlessness since 10days and epigastric pain since 4days 

History of present illness
The patient was apparently asymptomatic 3 months back.Then he developed fever and chills for which he went to a hospital where he was diagnosed with mild grade anemia then he used medication for 1 month. Then 1 month back the patient developed heavy fever and weakness and dyspnea on exertion.Since 1 weak the patient developed SOB. 
1day back she developed a grade 4 SOB then he was brought to the hospital 

History of past illness:
The patient is not a known case of diabetes,asthma,epilepsy and hypertension 


Personal history:
Diet- mixed
Appetite- normal
Sleep- decreased 
Bowel Movement’s - regular
Addictions: none. 
No burning micturition

Family history :
No significant family history

Treatment history:
No Diabetes
No HTN
No asthma
No Blood transfusions
2 caesarean sections done. 

PHYSICAL EXAMINATION 

GENERAL : 

Pallor present 

No icterus 

No cyanosis 

No clubbing of fingers 

No lymphadenopathy 

No Oedema of feet 

Mild malnutrition 

No dehydration 

Pulse rate : 86/min 

Respiration rate : 16/min 

BP : 140/80 mm/hg 

SPO2 at room air 98% 

INVESTIGATIONS













SYSTEMIC EXAMINATION 

CARDIO VASCULAR SYSTEM 

No thrills 

S1 S2 cardiac sounds 

Cardiac murmurs - NO 

RESPIRATORY SYSTEM 

Position of trachea - central 

Breath sounds - vesicular 

ABDOMEN 

Tenderness - not 

Palpable mass - no 

CENTRAL NERVOUS SYSTEM 

Conscious 

Speech - normal 

Reflexes are present 

PROVISIONAL DIAGNOSIS 

SEVERE ANEMIA. 

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