22 year old female with SOB

 Rambai 

Roll no 89 

NOTE: 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.

This is a case of 22 yr old,female, housewife by occupation came with c/o SOB since 20 days and generalized weakness since 20 days 

  Patient was apparently asymptomatic 6 yrs back then incidentally was found to have low Hb  for which she took medications for 3 months 

3 yrs ago ,when she was pregnant again was treated by injectable iron forms  for low haemoglobin (Hb -6) and anaemia was corrected 

Now patient came to OPD with c/o SOB even on rest with orthopnea and PND since 20 days 

Patient also has palpitations 

Patient also complains of generalized weakness since 20 days 

No h/o chestpain ,pedal edema and excessive sweating 

H/o fever which was high grade a/w chills and rigours and cough with productive sputum 20 days back for which she was treated in local hospital 

No h/o vomitings and loose stools 

No h/o worm infestations 

H/o pica in childhood ( used to eat slatepencils) 

PAST HISTORY: 

Not a k/c/o DM,HTN ,TB ,asthma , epilepsy 

Personal history: 

Diet - mixed 

Appetite - normal 

Sleep - adequate 

Bowel and bladder - regular 

No addictions and allergies

NUTRITIONAL HISTORY : 

Patient eat rice with curry 3 times a day 

Takes fruits occasionally 

ON EXAMINATION 

Patient is conscious coherent and cooperative 

pallor - present 

No icterus , clubbing, cyanosis,lymphadenopathy ,edema 

Vitals : 

BP- 100/600mmhg

PR -82bpm

Spo2 99% at room air 

GRBS - 92 mg/dl

Temperature 98.6F 

SYSTEMIC EXAMINATION:

Cvs: s1,s2 heard 

Rs: BAE present ,NVBS

P/A: soft, non tender  

CNS:

Pt is conscious, coherent, Cooperative 

Speech is normal

No meningeal signs

Normal cranial nerve examination, motor system, sensory system

Gcs: E4,V5,M6

 Reflexes:

       R       L

 B  ++      ++

T   ++       ++

S  ++       ++

K ++     ++

A   ++    ++

P  Flexor   Flexor   

INVESTIGATIONS 

BGT - A POSITIVE 

Reticulocyte count - 0.7 

Serum iron-  58.4 

Serology - negative 

Stool for occult blood - negative 

Blood urea - 14 

Se.LDH - 200

PROVISIONAL DIAGNOSIS:   

Iron deficiency anaemia ( microcytic hypochromic ) secondary to nutritional with heart failure with preserved election fraction (EF-62) secondary to anaemia 

TREATMENT GIVEN:  

  Inj.IRON SUCROSE 100 MG IN 100 ML NS /IV STAT

T.OROFER XT PO BD 

 T.LIMCEE PO OD