35/F WITH FATIGUE AND SHORTNESS OF BREATH
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Here is a case I have seen
Unit 6:
Case admitted in ICU on 6/2/2021.
Interns
K. Nikhil reddy
M. Swarna
K. Divya
B.Manivarma
Juveria
Dr. Vinay(pgy1)
Dr. Rashmitha(pgy2)
Dr. A. Vaishnavi (pgy2)
Dr. Sai Radha(pgy3)
Dr. Hareen (SR)
Dr.Praveen Naik( asst.prof.)
Dr.Rakesh Biswas (HOD)
Here is the case we have seen.
A 35 years old female , labourer by occupation came to casuality with
1. fatigue since 10-12 years , aggrevated since 1 year
2. Low grade fever since 10- 12 years
3. Shortness of breath since 2-3 years, aggrevated since 1 week
4.Pedal edema since 2-3 years.
Patient was apparently asymptomatic 10-12 yrs back, then she developed generalised weakness which is insidious in onset, gradually progressive,used to skip work, she is now unable to do her routine activities at home.Associated with low grade fever, headache on and off, decreased appetite.No cough, hemoptysis.
Patient gives h/o shortness of breath- intermittent, associated with pedal edema and used to visit local RMP for symptomatic relief.
Patient got hospitalised at NIMS 8 years back for 5-6 days with h/o pedal edema, Shortness of breath and was put on medication for ?anemia.
No H/o blood transfusions.H/o similar complaints 1.5 years back.
Shortness of breath aggrevated since 1 week on exertion, on less than ordinary physical activity like talking,climbing 2- 3 steps, walking to bathroom,associated with dry cough
No H/o orthopnea, PND,chest pain, palpitations, bleeding PR, vomitings, loose stools.
No known allergies,
No significant family history.
General examination:
Pallor +, koilonychia +, pedal edema+, Dark colored macules over anterior aspect of chest and anterior abdominal wall.
No H/o icetrus,cyanosis, clubbing.
Vitals:
Temp: afebrile
Bp:140/80mmhg
PR:87bpm
RR:22cpm
Spo2:99% at room air
GRBS: 126mg/dl.
Investigations:
ECG:
USG ABDOMEN:
CHEST X RAY:
PROVISIONAL DIAGNOSIS: SEVERE IRON DEFICIENCY ANEMIA (HYPOPROLIFERATIVE ANEMIA)
TREATMENT GIVEN:
1.Inj. LASIX 200mg /IV/sos if SBP>110mmhg.
2.1 PRBC TRANSFUSION
3. BP CHARTING HOURLY.
ON 7/2/2021.
S: Shortness of breath relieved.
No fresh complaints.
O: patient is conscious, coherent, cooperative
BP:100/60mmhg
PR:80bpm
RR:19 cpm
spo2:99% at room air.
CVS:S1,S2 heard, systolic murmur.
RS:BAE+, Clear.
P/A: Soft, non tender.
A:SEVERE IRON DEFICIENCY ANEMIA (HYPOPROLIFERATIVE ANEMIA)
P: 1.Bp, PR, RR charting 4th hrly
2.strict I/O charting
On 8/2/2021
S: Shortness of breath relieved, weakness decreased.
No fresh complaints.
O: patient is conscious, coherent, cooperative
BP:120/60mmhg
PR:68bpm
RR:20 cpm
spo2:99% at room air.
CVS:S1,S2 heard, systolic murmur.
RS:BAE+, Clear.
P/A: Soft, non tender.
A:SEVERE IRON DEFICIENCY ANEMIA (HYPOPROLIFERATIVE ANEMIA)
P: 1.Bp, PR, RR charting 4th hrly
2.strict I/O charting
On 9/2/2021
S: Shortness of breath relieved, weakness decreased,
Complaints of dry cough.
O: patient is conscious, coherent, cooperative
BP:100/60mmhg
PR:64bpm
RR:20 cpm
spo2:99% at room air.
CVS:S1,S2 heard, systolic murmur.
RS:BAE+, Clear.
P/A: Soft, non tender.
A:SEVERE IRON DEFICIENCY ANEMIA (HYPOPROLIFERATIVE ANEMIA)
P: 1.Bp, PR, RR charting 4th hrly
2.strict I/O charting
3. 1 PRBC transfusion
On 10/2/2021
S:Shortness of breath relieved, weakness decreased, no fresh complaints.
O: patient is conscious, coherent, cooperative
BP:110/60mmhg
PR:68bpm
RR:20 cpm
spo2:99% at room air.
CVS:S1,S2 heard, systolic murmur.
RS:BAE+, Clear.
P/A: Soft, non tender.
A:SEVERE IRON DEFICIENCY ANEMIA (HYPOPROLIFERATIVE ANEMIA)
P: 1.Bp, PR, RR charting 4th hrly
2.strict I/O charting
3. IV iron sucrose
On 11/2/2021.
S:Shortness of breath relieved, weakness decreased, no fresh complaints.
O: patient is conscious, coherent, cooperative
BP:110/70mmhg
PR:72bpm
RR:20 cpm
spo2:99% at room air.
CVS:S1,S2 heard, systolic murmur.
RS:BAE+, Clear.
P/A: Soft, non tender.
A:SEVERE IRON DEFICIENCY ANEMIA (HYPOPROLIFERATIVE ANEMIA)
P: 1.Bp, PR, RR charting 4th hrly
2.strict I/O charting
3. IV iron sucrose.
Patient discharged on 11/2/2021 ,2.00pm
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