A 65 year old male patient with iron deficiency anemia

November 7 , 2022

E LOG GENERAL MEDICINE 

Hi, we are G. Akshara , A .Shreshta , 3rd Sem Medical Students. 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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