A 22 YEAR OLD FEMALE WITH GENERALISED WEAKNESS AND EASY FATIGUABILITY

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.


A 22 yr old female who is a student came with complaints of generalized weakness and easy fatiguability since 2 months 

HISTORY OF PRESENTING ILLNESS

Pt was apparently asymptomatic 5  years back then she started to have desire to eat non edible material and went to the hospital and was diagnosed with Anemia (Hb 4gm/dl) and 2 units of PRBC transfusion was done . Since 2 months she is complaining of easy fatiguability with generalized weakness.

C/o SOB(grade ll-III) insidious in onset, gradually progressive to grade III , C/o exertional dyspnea.

No c/o chest pain, palpitations, orthopnea,pnd 

No c/o fever,loose stools, vomitings

PAST HISTORY

H/o similar complaints in the past

H/o two PRBC transfusion

N/k/c/o Diabetes, HTN,TB, Asthma, Epilepsy, Thyroid disorders 

PERSONAL HISTORY

Diet - Mixed

Appetite - Normal

Sleep - Adequate

Bowel and bladder - Regular

Addictions - No 

Daily routine 

7 am - Wakes up 

8 am -  Breakfast 

9 am - Coaching institute and comes back at 6 pm  

8 pm - Dinner 

10 pm - Sleep

Her daily routine did not changed even after illness


GENERAL EXAMINATION

Patient is conscious coherent and cooperative 

Pallor present

No Icterus, cyanosis, clubbing, generalized lymphadenopathy,edema 

Vitals-

Temperature- Afebrile

Bp - 110/80 mmHg 

PR - 92 bpm 

RR - 14 cpm


SYSTEMIC EXAMINATION

CVS - S1,S2 are heard

           No Murmurs 

P/A -  Soft, Non-tender

            No palpable spleen and liver

RS - Bilateral entry present

Normal Vesicular Breath sounds heard

CNS - NAD



                                                                        HEMOGRAM


                                                                        SERUM IRON 

                                                                        RETICULOCYTE COUNT


BLEEDING AND CLOTTING TIME

                                                                 RANDOM BLOOD SUGAR

                                                                                  CUE

                                                                            BLOOOD UREA


PHOSPHORUS


PERIPHERAL SMEAR 

FERRITIN


SERUM ELECTROLYTES


                                                                                  ECG


                                                                    FEVER CHART






PROVISIONAL DIAGNOSIS - IRON DEFICIENCY ANEMIA 

1 PRBC transfusion done On 8/07/2023

Hb raised to 7.6 mg/dl

1 PRBC transfusion done on 10/7/2023



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