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

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

DIAGNOSIS

IRON DEFICIENCY ANEMIA in

8/07/2023

1 PRBC transfusion done

Hb 7.6

10/7/2023

1 PRBC transfusion done

Comments

OSCE

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