23 F SOB since 20 days

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 CHIEF COMPLAINTS 

Fatigue,lassitude since 20 days 

Fever since 20 days 

Dragging type of leg pains since 20 days 

Progressive exertion dyspnea  since 20 days 

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 20 days back when she developed SOB which was insidious in onset and progressive in nature initially SOB only on performing ordinary physical activity (CLASS-2) later progressed to SOB even at rest (CLASS -4 NYHA ,SOB aggravates on lying down (orthopnea ) and at night after 2-5 hours of sleep due to which patient suddenly awakens (PND)  .SOB is associated with cough with sputum ,non blood stained ,non foul smelling ,palpitations which were fast regular beats ,lasting for 5 mins associated with breathlessness and relieve on rest ,not associated with sweating ,nausea vomiting ,loss of consciousness 

Right sided localised chest pain ,which is non radiating and aggravating on coughing , not seen at rest ,sleep .no wheezing 

Patient complaints of low grade fever since 20 days which is insidious in onset and high during early hours in morning later gradually comes down but complete relief is only after taking medication.

Fever is associated with chills and rigor ,no evening rise 

headache for which she was prescribed spectacles on the her previous visit to the ophthalmologist (not using ) 

Patient also complaints a dragging type of pain in legs extending from knee joint to the ankle joint which persists through the day ans even at night ,pain doesn’t hinder walking and other movements around the joints .

Patient complaints of generalised weakness ,giddiness since 20 days , reduced concentration ,reduced physical activity and motivation,loss of appetite and weight loss 

No h/o of recent upper respiratory tract infections ,cold ,loose stools ,worms in stools ,blood in stools,chest tightness ,blood in sputum ,use of inhalers , nausea vomiting ,pedal edema ,abdominal distension, seizures 

No H/O yellowish discolouration of eyes 

No h/o Reduced urine output 

No H/O cyanosis 

H/o of pica (used to eat slate pencils as a child )

MENTRUAL HISTORY 

AGE OF MENARCHE -13 years 

DURATION OF CYCLE -30 days 

No of days of bleeding -5 days 

No of pads used per day -(3-4 pads/day ) 

Associated with pains 

Not associated with clots 

Last mentrual period -

PAST HISTORY 

patient is a known case of anemia since the past 6 years , she was diagnosed incidentally 6 years ago for which she was prescribed oral iron tablets which she used for a duration of 3 months ,

Patient was married at the age of 19 years that is 3 years back (consanguineous marriage)

Pregnancy was attained 6 months after marriage spontaneously 

During her first trimester she was diagnosed with anemia in pregnancy (HB-6) and was put on oral iron tablets (twice daily)

During her second trimester since no improvement in HB levels were observed she was put on IV iron injections at 6 months and 8 months 

She delivered through NVD at term 

Male child 

 birth weight of 3.75kg 

Puerperium was uneventful 

Patient is hypotensive since 6 years 

not a known case of HTN,TB,DM, asthma ,thyroid disorders ,psychiatric illness,epilepsy 

FAMILY HISTORY 

no similar complaints in the family 

DRUG HISTORY 

Patient was taken in RMP for high grade fever for which she received injections 

patient uses dextrometorphan syrup in view of cough 

SURGICAL HISTORY 

no recent surgeries 

PERSONAL HISTORY 

23 year old female ,mother of one male child (3year old ) married at 19 years of age after 6 month of Marriage 

Farmer by occupation 

DIET -mixed

APPETITE -reduced since 20 days 

BOWEL AND BLADDER -regular 

SLEEP - reduced since 20 days 

ADDICTIONS,ALLERGIES -none 

GENERAL EXAMINATION 

patient is conscious , coherent and coperative 

Well oriented to time ,place and person 

Appears moderately built and moderately nourished 

Patient was examined in a well lit room after taking consent and with adequate exposure 

Pallor -present in the lower palpebral conjunctiva

Oral mucosa is pink  

Icterus -absent 

Cyanosis -absent 

Clubbing  -absent

Koilonychia  -present 

Lymphadenopathy  -absent

Pedal edema  -absent

Thyroid -non palpable 

Spine -normal 

Weight -40 kgs 

VITALS 

TEMP-a febrile 

PULSE RATE -82bpm normal rate ,normal rhythm increased volume ,normal character 

BLOOD PRESSURE -100/60mmhg

RESPIRATORY RATE -18cpm

SYSTEMIC EXAMINATION 

Cvs: s1,s2 heard 

Rs: BAE present ,NVBS

P/A: soft, non tender  

CNS:

Pt is conscious, coherent, Cooperative 

Speech is normal

All higher mental functions are intact 

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

Bilurubin - 0.73.

D. Bilurubin -0.25

SGOT (AST) - 18

SGPT (ALT) - 10.

alkaline phosphale - 149.

T. proteins - 7.1

Albumin -4.07

AG RAtO - 1.34.

PROVISIONAL DIAGNOSIS:   

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

TREATMENT GIVEN:  

Patient was administered 1 unit of PRBC transfusion on 7/4/2023

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

T.OROFER XT PO BD 

 T.LIMCEE PO OD