1801006071-Short Case

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A 45 yr old female home maker by occupation presented to opd with chief complaints of shortness of breath since 15 days

History of Presenting illness:

Patient was apparently asymptomatic 15 days ago . Then she developed shortness of breath which was insidious in onset gradually progressive and aggravated on stress, work(Class 2 NYHA ) and relieved on rest.Within to few days of onset of her shortness of breath it progressed to her unable to perform her daily activities( Class 3) so she went to local hospital were her haemoglobin levels were found to be low (3.6) and she was advised to our hospital for blood transfusion.

No history of chest pain , sudden grasping of air at night,Orthopnea.

Past History:

She had a previous blood transfusion of 3 packs 1 yr back  since on her hospital visit for  menoragghia she was found to be having low haemglobin 

Known diabetic since hospital admission.

Not a known case of hypertension, epilepsy ,Asthma, coronary artery disease or chronic kidney disease.

Menstrual history:

Age of menarche 12 yrs

Previous cycles were 3/30 with no pain and clots

Since 1 yr she is having 5/20 with heavy menstrual bleeding with no pains and clots and she went to hospital and was diagnosed with fibroids and was advised hysterectomy and then on routine investigations because of her low hb surgery was postponed and she was given blood transfusions and her hb raised to 8 gm% which was not adequate for surgery and as she qas approaching menopause on advise of her relatives she didnt want surgery 

Personal History:

Diet Mixed

Appetite normal

Bladder and bowel movements regular

Sleep adequate

Allergies none

Addictions none

Family History-

Not significant 

Clinical Images:

GENERAL EXAMINATION-

Patient is conscious coherent and co operative well oriented to time place and person moderately built and nourished.

Pallor-present

Icterus - Absent

Clubbing- Absent

Cyanosis- Absent

Lymphadenopathy- Absent

Edema - B/l on both lower limbs till knees pitting type 

Vitals:

Temperature afebrile

Pulse rate 118 beats per minute

Blood pressure 110/70mm of Hg

Spo2-97%

Respiratory rate 18cycle per minute

Systemic Examination:

CVS

JVP elevated

Inspection:

Position of the trachea is central. 

Apical impulse is observed. 

No visible pulsations, dilated and engorged veins, scars. 

Palpation:

Apex beat was localised in the 5th intercostal space 1cm lateral to mid clavicular line.

Position of trachea was central 

No parasternal heave , thrills.

Auscultation: 

S1 and S2 were heard 

No murmurs. 

Respiratory system:

Bilateral air entry is present 

Normal vesicular breath sounds are heard

PER ABDOMEN-

Soft non tender

No organomegaly

C section scar visible.

CNS -

No focal neurological deficit.

Investigations:

Complete Blood Picture:

Hemoglobin:3.6gm%

RBC 2.11 million/mm3

MCV:73.5 fl

MCH:17.1 pg

MCHC: 23.2 %

PCV:15.5 vol%

Peripheral smear:

Anisopoikilocytosis  with Macrocytes,Macro ovulacytes,Microcytes pencil drops and tear drops.

Complete urine examination:

Color-pale yellow

Appearance- clear

Specific gravity-1.010

Sugar-nil

Albumin:+++

Pus cells:4-8hpf

Epithelial cells-3-4/hpf

ECG:

Xray:

Provisional Diagnosis:

Dimorphic anemia 

Heart Failure secondary to anemia.

Treatment:

Transfuse Packed Red blood cells

Tab Order Xt 

Inj Vitamin B12 

Inj Lasix 40mg .