60years Female with c/o Shortness of breath

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Chief Complaints:

A 60 years old female patient resident of Anthampet and a laundry worker by occupation, came on medical OPD on 7-12-2022 with chief complaints of:-

*Shortness of breath,weakness, fatigue since 1month

History of Present Illness:

*Patient is apparently asymptomatic 4years ago , when she started to develop shortness of breath,which was insidious in onset, gradually progressive 

*H/O Fever , weakness 

*No H/O pedal edema

History of Past illness:

*H/O- Hypertension since 10years on regular medication (using TAB-AMLODIPINE+ATENOLOL  PO/OD)

*PRBC Blood transfusion 2PRBC 4years ago and 3PRBC 6months ago

*No H/O-Diabetes, Asthma,TB,CAD, Epilepsy

Personal History:

Diet:Mixed

Appetite:normal

Sleep: inadequate

Bowel and bladder movement: regular

Menstrual history:

Age of menarche:16years

Days of cycle:28days

Age of menopause:48years

Family History:

No history of Diabetes, Hypertension,TB, Epilepsy,CAD in family members

General Examination:

Patient is conscious, coherent and cooperative.

Moderately built and nourished.

Her consent is taken.

She is examined in a well lit room after adequate exposure.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema.

Vitals:

Temp: Afibrile

Respiratory rate:18cycles/min

Pulse:80bpm

Blood pressure:110/60mmHg

Sp O2 :97%

GRBS:137mg/dl

Systemic Examination:

Cardiovascular Examination:

Inspection: 

- Bilaterally symmetrical chest wall

- Movements - symmetrical

- Skin normal - no scars, sinuses seen.

- Apex impulse not seen.

- No visible pulsations.

- No parasternal heaving seen.

- JVP - not raised.

Palpation: 

- No local rise of temperature and tenderness.

- Bilateral symmetrical chest movement.

- Apex beat - Felt in the left 5th intercostal space - in mid clavicular line.

- Parasternal heave - absent.

- No visible pulsations.

Percussion:

- Right heart border - about 1cm to right of sternum.

- Left heart border - about 2cm lateral to mid clavicular line.

Auscultation:

- S1 and S2 heard 

- murmur - absent

Respiratory system:

Position of trachea: Central

Breath sounds:No

Adventitious sounds:No

Abdomen

Shape of abdomen: Scaphoid

Tenderness:No

Palpable mass:No 

Henias orifices: Normal

Free fluid:No

Bruits:No

 

Liver:Not palpable

Spleen: Not palpable

Bowel sounds:Yes

Central Nervous system:

 Pt is conscious

Speech:Normal

Signs of meningitis:No 

Cranial nerves: Normal

Motor and sensory system: Normal

Provisional Diagnosis:

IDA (Iron Deficiency Anemia)

Investigation:

Ultrasound:-

Treatment:

RX:-

Inj.IRON SUCROSE 200Mg in 100ml of NS   OD/IV(alternate days)

Tab.AMLONG AT    PO/OD(1-0-0)

Monitor vitals 6hourly