1801006067 short case


This is a case of a 54 year old woman who is a house wife and a resident of Munugodu. She came with the CC of Shortness of breath and generalised weakness since 2 days.

HOPI-

Patient was apparently asymptomatic 8 months back (around December 2021) then she had shortness of breath which was insidious in onset and continuous which aggravated on walking and lying down and relieved on sitting. 

H/o cough associated with SOB, non productive and intermittent.

H/o Fever since 8 months which was Intermittent, and relieved on medication (PCM and Dolo)

Back then she went to a Local Hospital in Nalgonda. She had low Hb levels for which she underwent blood transfusion.

1 month back she had her Hb around 5 g/dl and she underwent Blood transfusion again And her Hb raised to 8g/dl.

No H/o Blood in stools, Trauma

Past History:

Not a known case of  DM, HTN, Asthma, Epilesy.

History of Pulmonary Tuberculosis 6 years back and used Medication.

History of Hyperthyroidism since 4 years ( on carbimazole)

Personal History:

Appetite - Decreased

Diet- Mixed

Sleep- Adequate

B&B- Regular

Surgical History:

Hysterectomy 30yrs back due to heavy bleeding.

Family History: Not Significant

On Examination-

Patient is conscious, coherent and cooperative, thin built and undernourished well oriented to time, place and person.

Vitals

BP: 120/70 mm hg

PR: 70 bpm

RR: 20cpm

Temperature: 98.6*F 

SPO2: 95%

GRBS: 106mg/dl

Pallor : present

Icterus: absent

Cyanosis: absent

Clubbing : absent

lymphadenopathy:absent

B/l Pedal edema: Absent

Systemic Examination: 

CVS: S1 and S2 + , no murmurs

CNS :NAD

P/A : Soft and non tender

RS :BAE+

Inspection:

Trachea position is central

Chest - Symmetrical.

Palpation:

All inspectory findings are confirmed by palpation

Trachea is central

Chest is symmetrical with

AP diameter : transverse diameter =5:7

Symmetrical expansion of chest

Vocal fremits is felt

Percussion:

Resonant on percussion

Auscultation

Breath sounds - normal

Investigations -

1/8/22

CUE- Normal

Reticulocyte Count- 1%

ESR- 110 mm/1st hour

ECG-





Peripheral Smear:


USG-


X-Ray










Clinical Pictures:










Follow up -

2/8



3/8



4/8


Provisional Diagnosis -
Anaemia under evaluation.
?CRF



 





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