17 YEARS OLD FEMALE WITH C/O GENERALISED WEAKNESS AND SOB

 MEDICAL CASE

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I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my cmpetancy i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

March 4 2022

YOGITA AILANI

Roll no:149

A 17year old female patient student by occupation came to the hospital in early march with chief complaints of

• Generalized weakness since 2to3years.
• Since 2months she complaining of shortness of breath on exertion,palpitations,fatiguability.
• Episodes of chest pain on/off.

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 3years back then she developed generalized weakness.

She developed shortness of breath on exertion(climbing uphill), palpitations and then she visited the government hospital and the doctor suggested to take iron tablets and also suggested blood test to be done by looking at her eyes (pallor).she taken the medication irregularly.

Then she went to get COVID vaccination 2 days back where she got blood test done and she get to know her HB value is 2.3.

There is a history of pica since childhood.

There is no history of fever,blood in stools, hemorrhoids.

There is no history of jaundice in the past.

No history of blood loss.

No history of seizure attack.

PAST HISTORY:-

Not a k/c/o of DM,HTN,thyroid disorders,BA,TB,epilepsy

No history of blood transfusion inthe past

No history of past surgeries.

MENSTRUAL HISTORY:-

She attained Menarche at the age of 16years

Regular,4days /30day cycle

Uses 3pads/day

Not associated with pain,clots.

LMP:16/2/22

For 3months she has polymenorrhea she menstruates 4 days/15 day cycle

PERSONAL HISTORY:-

Appetite:Normal

Diet:Mixed

Sleep: Adequate

Bowel habits: constipation since 2 to 3months

Bladder habits:regular

No addictions

FAMILY HISTORY:-

No similar complaints in the family

GENERAL EXAMINATION:-

Patient is conscious , coherent and cooperative and well oriented to time place 

and person, 

Thin built and moderately nourished

Pallor- present

Icterus- Absent

Cyanosis- Absent

Clubbing- Absent

Lymphadenopathy- Absent

Edema: Absent

VITALS:

TEMPERATURE: Afebrile

PULSE RATE:90 beats /min

RESPIRATORY RATE:18Cycles/min

BP:110/60mm of hg 

SPO2:97% at room air

SYSTEMIC EXAMINATION:

CVS:

S1,S2 Sounds heard,

No audible murmurs,

Thrills:No.

RESPIRATORY SYSTEM:

Dyspnea is present,

Position of trachea:central,

Normal vesicular breath sounds are heard,

No adventitious sounds  

P/A :

Shape of abdomen :scaphoid

Soft and non tender abdomen

Spleen is palpable upto 5cms below the left costal margin.

Bowel sounds heard 

CNS EXAMINATION:

Higher mental functions intact 

Cranial nerve examination normal

INVESTIGATIONS:-

On 26-02-2022

Hb: 2.3

TLC: 3400

Peripheral smear: ANISOPOIKLOCYTOSIS WITH MICROCYTIC HYPOCHROMIC CELLS, TEARDROP CELLS, PENCIL FORMS, NORMOCYTES

Blood group: B+ve

Rcc: 1%

On 28-02-2022

ESR: 20

LFT:

TB : 0.98.

DB : 0.24

SGOT : 26

SGPT: 17

ALP : 201

TP :7. 4

Albumin : 4.5

RFT:

Sr Urea : 16

Sr Crt : 0.5

Uris acid : 2.3

Na+ : 140

K+ : 4.0

Cl- :102

Sr IRON : 50 (37-145)

Sr ferritin : 1.3 (23.9-336.2)

COLOUR DOPPLER 2DECHO

USG

On 01-03-2022

Hb: 5.1

TLC: 2500

Sr LDH: 249

ECG

On 02-03-2022

Hb: 4.8

TLC: 2300

On 03-03-2022

Hb: 7

TLC: 2600

On 05-03-2022

TREATMENT:-

1/03/2022:

1)Monitor vitals

2)Inj.Nervigen1amp in 100ml of NS i.v OD over 1hr

3)T.Orofer-XT OD

2/03/2022:

1)Inj.Nervigen 1amp in looml of NS OD

2)T.Orofer-XT

Given 2 Units of PRBC

3/03/2022:

1)Inj.Nervigen 1amp in 100ml of NS OD

2)T.Orofer-XT OD

3)T.Matilda forte OD

4/03/2022:

Inj.Nervigen 1amp in 100ml of NS OD

2)T. Orofer-XT OD

3)T.Matilda forte OD

5/03/2022:

1)Inj.Nervigen 1amp in 100ml of NS i.v OD

2)T.Orofer-XT OD

3)Monitor vitals

4)T.Neuroblan forte PO OD

5)T.I.D 826 mg

200mg given yesterday  Iron sucrose