A 65 year old patient with iron deficiency anemia
A 65 year old male patient with iron deficiency anemia
November 7 , 2022
E LOG GENERAL MEDICINE
Hi, I am G . Hruthik 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.
This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.
* This is an ongoing case. I am in the process of updating and editing this ELOG aChief complaints and duration.
Chief complaints :
A 65 year old male farmer from nagarjuna sagar came with
cheif complaints of :
Dizziness and decreased appetite from 5-6months
Pedal edema and facial puffiness since 1 week.
History of present illness :
Patient was apparently asymptomatic 6 months ago,then he developed dizziness,decreased appetite, insomnia, body pains and generalised weakness.
One week ago, he developed pedal edema and facial puffiness.
Polyuria associated with burning micturition.
SOB present.
On visiting a local hospital, his blood haemoglobin levels were found to be low, for which he was administered iron supplements and asked to undergo a blood transfusion.
Past history :
TB- 30 years ago
No h/o diabetes
No h/o hypertension
No h/o asthma
No h/o Epilepsy
No h/o Syphilis
Family history :
Non significant
Personal history :
Diet : mixed
Appetite: decreased
Bladder : polyuria and burning micturition
Bowel: regular
Sleep : inadequate
Addictions: alcoholic
No allergies
PHYSICAL EXAMINATION :
General examination :
Conscious , coherent and cooperative
Pallor is present.
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
Pedal edema is present since a week.
Vitals :
Temperature: 98.6 F
Pulse: 82
Respiration: 18/min
Blood pressure: 110/70 mmHg
Spo2: 98%
SYSTEMIC EXAMINATION :
A.Cardio vascular system :
Cardiac sounds : S1 and S2
No thrills
No murmurs
B.Respiratory system :
Dyspnoea : absent
Wheeze : absent
Position of trachea : centre
Breath sounds : vesicular
C.Abdomen :
Shape of abdomen : scaphoid
No tenderness
No palpable mass
No palpable liver
No palpable spleen
Ultrasound :
ECG :
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