22 year old female with easy fatiguability and generalized weakness since 2 months

22 year old with easy fatiguability and generalized weakness
8th July, 2023

Hello, I am Harika Madala, a 5th sem medical student.
THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

Chief complaints
Easy fatiguability since 2 months
Generalized weakness since 2 months

History of Present Illness
Patient was apparently asymptomatic 2 months back then developed easy fatiguability, generalized weakness
Patient also complained of shortness of breath (Grade II-III), insidious in onset, gradually progressive to grade-III

No other complaints of cheat pain, palpitations, orthopnoea, constipation 
No complaints of fever, loose stools, vomitings
No bleeding from mouth and gums
No history of joint pains


History of Past Illness
Patient gave history of similar complaints in the past
History of Blood transfusion
Not a k/c/o Hypertension, Diabetes Mellitus,
Asthma, thyroid disorders

Treatment history
Blood(2 units) transfusion in the past 5 years back

Personal history
Single
Student
Normal appetite
Mixed diet
Adequate sleep 
Regular bladder & bowel movements
No allergies
No addictions

Family history
No significant family history

Menstrual history
Attained menarche at the age of 14 yrs
Regular cycles
Flow 5/28 days

Physical examination
General examination
Patient was conscious, coherent, cooperative
Moderately build and nourished
Pallor +
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Vitals
Blood Pressure- 110/70
Pulse Rate- 98/min
Respiratory rate- 16/min
Temperature- 98.6 F
SpO2- 98%

Systemic examination
Cardiovascular system
Thrills - No
Cardiac sounds- S1 S2 heard
Cardiac murmurs - No
Respiratory system
Dyspnoea - no
Wheezing - no
Position of trachea - Central
Breath sounds- Vesicular
Adventitious sounds - Rhonchi
Abdomen
Shape of abdomen - Scaphoid
Tenderness - no
Palpable mass - no
Hernial orrifices - normal
Free fluids - no
Bruits - no
Liver - Not palpable
Spleen - Not palpable
Bowel sounds - Yes
Central Nervous System
Conscious
Normal speech
No neck stiffness
Cranial nerves intact
Sensory & Motor system intact
Reflexes
                           Lt               Rt
Biceps              +2               +2
Triceps             +1              +1
Supinator        +1               +1
Knee                 +2               +2  
Ankle                +1              +1
Investigations
ECG
Provisional diagnosis
 Anemia 





























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