A 42 years old female with SOB on exertion and generalised weakness.

July,7 2022

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CASE:

A 42 yrs old female resident of chityal,hotel worker by occupation came with the cheif complaints of SOB on exertion and generalised weakness since 1 month.

HISTORY OF PRESENTING ILLNESS:

 Patient was apparently asymptomatic 1 month back and then she noticed SOB on exertion(while doing work) since 1 month and stopped her work 20 days back,ggeneralised weakness since 1 month.

No h/o fever,cough ,PND, orthopnea and wheez.

SEQUENCE OF EVENTS:

5 years back(in 2017) patient had chest pain  and SOB on exertion and was diagnosed with anemia and had PRBC transfusion.she used to take oral iron(orofer) for 1 yr after that.

In 2021,August  she came with complaints of headache(right occipital region),vomitings and giddiness and was on conservative treatment.she had one more PRBC transfusion in nalgonda gov. hospital as she couldn't afford money for blood transfusion here.

Now,she complaints of left ear pain and left ear discharge since 1 month and diagnosed with otomycosis,is on medication(candid drops)

DAILY ROUTINE:

She used to wake up in the morning at around 5 AM.she used to do all her household work and gets fresh up.she used to cook food for her daughter and sends her to the school.she has a cup of tea with biscuits and goes to work at 7 AM(hotel worker-floor cleaning,table cleaning and cleaning utensils in hotel).she has her breakfast at 11 AM in the hotel itself and continues her work.she has her lunch at 3 PM again in hotel.she returns home in the evening at around 6 PM and cooks food at home for dinner.she has her dinner at 8-9 PM and goes to bed at 10 PM.

PAST HISTORY:

No h/o diabetes,HTN,asthma,epilepsy.thyroid abnormalites and previous h/o surgeries.H/o of blood transfusion 2 times.

PERSONAL HISTORY:

Diet:vegeterian (also eats egg)

apetite:nornmal

bowel and bladder:regular

sleep:adequate

addictions:no addictions.

FAMILY HISTORY: No H/o similar complaints in the family.

MENSTRUAL HISTORY:

Regular menses-3 days, no clots , normal flow.

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative.

Well oriented to time place and person.patient is lean and malnourished.

Pallor: present.                  

 

Icterus: absent

clubbing: absent

cyanosis: absent

Lymphadenopathy: absent

Edema : absent

VITALS: 

Temp: afebrile

BP: 140/90 mmHg 

PR- 82 bpm

RR- 17 breaths per min 

 

SYSTEMIC EXAMINATION:

Cardiovascular system- s1 and S2 are heard no murmurs are heard

Respiratory system:

trachea central, all quadrants of chest moves equally with respiration.

Breath sounds- bilateral normal

Vesicular breath sounds are heard.

Central nervous system- Patient was conscious, coherent and cooperative

Speech was normal.

No slurred speech.

abdominal examination :

Inspection:flat abdomen, umbilicus centre and inverted.

Palpation:soft,non-tender,enlarged spleen,

percussion:no shifting dullness, no fluid thrills.

auscultation:normal bowel sounds are heard.

INVESTIGATIONS:   

 

   

PROVISIONAL DIAGNOSIS:

microcytic hypochromic anemia(IDA?)