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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 














o








DIAGNOSIS

IRON DEFICIENCY ANEMIA in

8/07/2023

1 PRBC transfusion done

Hb 7.6

10/7/2023

1 PRBC transfusion done


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