A 40 year old female 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 who works in the hotel     she is aresident of Narketpally came with chief complaints of

Increased heartbeat since 6 months

Breathlessness since 6months

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 6 months back then she developed palpitations which were sudden onset, gradually progressive and develops under stressandheavy work.The palpitations lastsfor 2 to 3 min and relives on rest .But Since  last 2 to 3 months she complains of increased frequency and intensity of palpitations making her worry

She also complains of breathlessness ( shortness of breath) since 6 months and it was gradually progressive from grade 1(6months back)to grade 3 (presently like she is getting sob while she was changing her clothes also) and it relieves when she takes rest.

Patient also has occasional dizziness  and 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.

She has acidity from past 15 years back

She develops burning sensation in abdomen when she consumes oily food, spicy foods, and chapati.And for this she takes omeprazole every morning half n hr before food.

7 years back She had severe vomitings and diarrhea for which she went to gastroenterologist and got endoscopy colonoscopy done and was diagnosed with irritable Bowel syndrome she then took medication for one year.

After that since she has acidity she takes medications  to reduce her acidity which are not prescribed by doctor 

No history of prolonged hospital stay or surgeries.

She had sore throat 2 months back for which she consulted Local RMP 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 gets fresh up

Does household work( sweeping, cleaning dishes,cooking)

She takes her breakfast at 8.30 am

From 9 am to 2pm she starts preparing items like cutting vegetables and cleans tabels and cleans the hotel and she sits in the counter

She takes her lunch at 2pm

And from lunch to dinner she sits in the counter and at 5pm she drinks tea

 At 9pm she eats her dinner

From 9pm to 10pm 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- no addictions 

Allergies -no addictions 

GENERAL EXAMINATION 

Patient was conscious,coherent, cooperative 

Well oriented to time, place ,person

Poorly built and poorly nourished 

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 in the abdomen

Percussion

    No significant findings 

    

Auscultation 

    Bowel sounds heard

    No bruits

RESPIRATORY EXAMINATION 

Trachea central

Normal vesicular breath sounds Heard 

Bilateral air entry present.

CARDIOVASCULAR SYSTEM

S1S2 heard

No murmurs

CENTRAL NERVOUS SYSTEM

No focal neurological deficits

Investigations:

PROVISIONAL DIAGNOSIS

Dimorphic anemia 

Secondary to nutritional cause

IDA?

Folate deficiency anemia?

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 Livogen  IM PO OD every alternate day

Tab esomeprazole 20mg PO OD (7am)

Vitals monitoring every 6th hrly.