General medicine elog

1 July ,2022 

33 yr old female with Moderate MR and severe PAH

Hi, I am Ananya Nayak, 3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

A 33yr old female patient came who is a housewife and a resident of Bengal came to the OPD with chief complaints of Shortness of breath and bilateral  knee joint pain.She was admitted in the SS Ward on 


HISTORY OF PRESENT ILLNESS-
 
The patient was apparently asymptomatic 2yrs back.
Then she developed shortness of breath which gradually aggrevated on lifting heavy objects and exertion. 1 year back she developed bilateral knee joint pain which gradually aggrevated on exertion and subsided at rest.

Onset-insidious 
The pain was progressive for which she went to a hospital in Bengal and was treated conservatively.It subsided after taking medications but after the medications were over the symptoms reappeared.

 2 months ago,patient presented with increased SOB along with chest pain especially while breathing out and palpitations.She even had complaints of reduced appetite and disturbed sleep for which they went to  a hospital in Siligudi and it subsided with medications.

Sometimes she had complaints of swelling in her legs when patient used to walk for a long time associated with knee pain.

Since 5 months,she developed irregular menses.


HISTORY OF PAST ILLNESS-
No significant past illness found.
She had severe covid 2yrs back,high grade fever.

FAMILY HISTORY-No significant family history found.

PERSONAL HISTORY-
Married 
Diet-mixed 
Sleep-adequate
No burning micturition 
Bowels-regular 
No addictions
No allergies 

NEGATIVE HISTORY-
No case of epilepsy, asthma,HTN,DM,TB

GENERAL EXAMINATION-
Poorly nourished and thin built
No icterus
No pallor 
No cyanosis 
No lymphadenopathy 
No clubbing of fingers
No edema

VITALS-
Temperature-98.6
Pulse rate-82 beats/min
Respiration rate-16 beats/min
BP-110/80 mm of Hg
SPO2-98%


SYSTEMIC EXAMINATION-

RS-BAE+

CVS-S1,S2 +,Loud S1

PA-Soft,non tender

CNS-NAD


INVESTIGATIONS ORDERED-

2D ECHO,ECG,CHEST X-RAY,RFT,HEMOGRAM,USG ABDOMEN.,PFT



















PROVISIONAL DIAGNOSIS-

Moderate MR, Severe PAH and Severe Mitral Stenosis with Rheumatic heart disease.


TREATMENT-

Tablet LASIX 40mg












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