A 35 year old female came with the headache,neck pain, generalised weakness since 3 days
Chief complaints:
DIAGNOSIS: anaemia under evaluation ?IDA
A 35 year old female came with the
-complaints of neck pain and head ache since 3 days
-complaints of generalised weakness, giddiness since 3 days
-complaints of shortness of breath on and off since 3 days
HOPI:
Patient is fine since 10 years now she is complaining of neck pain ,headache since 3 days and associated with generalised weakness ,giddiness since 3 days patient is feeling breathless- having breathless episodes and is then waiting up from sleep, subsides in 3 to 5 minutes, SOB on walking grade 2 on and off since 3 days, outside HB 5.0gm/dl was referred to our hospital .
No complaints of any bleeding manifestations.
Now no complaints of fever menorrhagia, tingling of limbs ,vomitings loose stools.
Non DM,HTN,thyroid disorder.
Past history:
17 years ago history of menorrhagia for 1 month - Hb-3mg/dl, 5. PRBC transferred.
15 years ago birth of male child, no complications
13 years ago ?septic abortion, 2.PRBC transferred i/v/o anemia
10 years ago during pregnancy was transfused with iron injections -birth of female child (after 4 years child died with febrile seizures)
Diet-leafy vegetables rarely once in a month or 2 months ,non veg rarey chicken ,fish .eats mutton once a week or once two weeks, eats vegetables daily
GENERAL EXAMINATION:
Temperature 98.6 F
Pulse-63bpmRR:18cpm
BP-120/70mm Hg
Spo2-98% @RA
No pigmented knuckles
SYSTEMATIC EXAMINATION:
PER ABDOMEN:Soft, non tender
No guarding, No rigidity
Bowel sounds present
CARDIOVASCULAR SYSTEM:
S1,S2 heard, NO Murmurs
RESPIRATORY SYSTEM:
BAE present,NVBS
CENTRAL NERVOUS SYSTEM:NAD
INVESTIGATIONS:
Plan of treatment
1. Plan 1.PRBC
2.Tab.OROFER PO OD
