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

 A 22 yr old female who is a student came with complaints of generalized weakness and easy fatiguability since 2 months 

History of Presenting illness

Pt was apparently asymptomatic 5  years back then she started to have desire to eat non edible material and went to the hospital and was diagnosed with Anemia (Hb 4gm/dl) and 2 units of PRBC transfusion was done

Now since 2 months she is complaining of easy fatiguability with generalized weakness 

C/o SOB(grade ll-III) insidious in onset, gradually progressive to grade III,c/o exertional dyspnea 

No c/o chest pain, palpitations, orthopnea,pnd 

No c/o fever,loose stools, vomitings

PAST HISTORY

H/o similar complaints in the past

H/o two PRBC transfusion

N/k/c/o diabetes HTN TB Asthma Epilepsy thyroid disorders 

PERSONAL HISTORY

Diet  Mixed

Appetite normal

Sleep adequate

Bowel and bladder  regular

Addictions No 

Daily routine 

Pt wakes up around 7 am takes breakfast and goes for coaching institute and comes back at 6 am and takes dinner at 8 pm and sleeps around 10 pm 

Her daily routine did not changed even after the illness


General Examination

Pt is conscious coherent and cooperative 

Pallor present

No Icterus, cyanosis, clubbing generalized lymphadenopathy,edema 

Vitals 

Temp afebrile

Bp 110/80 mm Hg 

PR 92 bpm 

RR 

Systemic Examination 

Cardiovascular system 

Inspection : 

Shape of chest- Normal

No engorged veins, scars, visible pulsations 

Palpation :

Apex beat can be palpable in 5th inter costal space medial to mid clavicular line


No thrills felt

Auscultation : 


S1,S2 are heard


No Murmurs 


Inspection - 

Umbilicus - inverted

All quadrants moving equally with respiration

 No scars, sinuses and engorged veins , visible. pulsations. 

  Hernial orifices- free.

Palpation -  

soft, non-tender

no palpable spleen and liver

Percussion:Resonant note heard

Auscultation- normal bowel sounds heard 

Respiratory system 

Bilateral entry present

Normal vesicular breath sounds heard

CNS NFD 





Investigations 


















 


 





DIAGNOSIS

IRON DEFICIENCY ANEMIA in

8/07/2023

1 PRBC transfusion done

Hb 7.6

10/7/2023

1 PRBC transfusion done

Discharge summary

Diagnosis 

IRON DEFICIENCY ANEMIA ?NUTRITIONAL ANEMIA WITH 2 UNITS OF PRBC TRANSFUSIONH DONE ON 8/7/23 AND 10 /7/23.

 Case History and Clinical Findings

 C/O EASY FATIGUABILITY SINCE 2 MONTHS C/O GENERALIZED WEAKNESS SINCE 2 MONTHS

 HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS BACK ,THEN DEVELOPED WEAKNESS . C/O SOB,GRADE II - III ,INSIDIOUS IN ONSET ,GRADUALLY PROGRESSIVE TO GRADE III NO OTHER COMPLAINTS OF CHEST PAIN ,PALPITATIONS ,ORTHOPNEA ,PND . NO C/O FEVER,LOOSE STOOLS,VOMITINGS. H/O SIMILAR COMPLAINTS IN THE PAST (H/O BLOOD TRANSFUSION WITH PRBC )NO RERACTIONS .                              

HTN DM/ASTHMA/THYROID DISORDERS-. 

O/E:

 PT C/C/C PALLOR+ TEMP:98.6 F PR:98 RR:16 BP:110/70 CVS:S1S2+,NO MURMURS. RS :BAE +,NVBS. P/A :SOFT,NON TENDER . NO ORGANOMEGALY .

 COURSE IN HOSPITAL:

 PATIENT WAS ADMITTED IVO FATIGUABILITY AND GENERALIZED WEAKNESS SINCE 2 MONTHS AND WAS INVESTIGATED FURTHER AND MANAGED CONSERVATIVELY WITH 2 UNITS OF PRBC TRANSFUSION DONE ON 8/7/23 AND 10/7/23 . PATIENT IS HEMODYNAMICALLY STABLE AT TIME OF DISCHARGE. Investigation IRON PROFILE: IRON :11 UG/DL TIBC:548 UG/DL TRANSFERRIN SAT %:2.O . FERRITIN:1.5NG/ML HEMOGRAM: HB:8.9 GM/DL TC:8700 NEU:67 LYM:67 MON:05 EOS: 02 RBC : 4.31 PCV:27.2 MCV : 63.1 MCH:17.6 MCHC : 27.9 RDW CV: 27.8 DRW SD: 61.2 USG ABDOMEN : IMPRESSION: NO SONOLOGICAL ABNORMALITY DETECTED . 

2D ECHO:  

NO MR/AR/TR NO RWMA.NO AS/MS GOOD LV SYSTOLIC FUNCTIONS NO DIASTOLIC DYSFUNCTION ,NO PAH/PE EF:65%,FS :32%. HEMOGRAM:-(11/07/2023) HB-8.9GM/DL TOTAL COUNT-13,700CELLS/CUMM NEUTROPHILS-62% LYMPHOCYTES-28% EOSINOPHILS-01% MONOCYTES-09% BASOPHILS-00% PCV-30.9VOL% MCV-67.2FL MCH-19.3PG MCHC-28.8% RBC -4.60MILLIONS/CUMM PLATELETS-3.15LAKHS/CU.MM 

Treatment Given(Enter only Generic Name) 

1) 2 UNITS OF PRBC TRANSFUSION ON 8/7/23 AND 10/7/23. 2)TAB.OROFER .

 Advice at Discharge

 TAB.OROFER -XT PO OD FOR 3 MONTHS. TAB.MVT PO/OD FOR 10 DAYS. 

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