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
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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:
Provisional Diagnosis:
Dimorphic anemia
Heart Failure secondary to anemia.
Treatment:
Transfuse Packed Red blood cells
Tab Order Xt
Inj Vitamin B12
Inj Lasix 40mg .
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