Anaemia case

General Medicine E-log

A 22 year old female presented to the OPD with complaints of generalised weakness since 2 months.

Chief Complaints: 

A 22 year old female student, resident of Choutuppal came to the OPD with complaints of generalised weakness since 2 months.

History of presenting illness:

The patient was apparently asymptomatic 5 years ago when she started feeling extremely weak and used to tire easily, she came to KIMS for a check up. She was told that she had Hb levels of 3g/dl. She was admitted and received 2 blood transfusions for it over a period of 1 week. 

Since 2 months she had been feeling weak again. It was accompanied by shortness of breath (grade 2). It occurred on climbing stairs and needed breaks to catch her breath.

It was not associated any feeling of dizziness, headache, fainting, shortness of breath, noticeable heartbeat, chest pain, blood in stools, abnormal food cravings,

She visited the hospital on the 20th of June and her blood test showed Hb levels of 5.1g/dl. She was advised to get admitted but she refused as she had exams coming up. When she returned to the hospital for a check up on the 7th of July, her Hb levels had fallen to 4.7 g/dl. She was admitted immediately and 1 bag of blood was transfused on 8th July after which her Hb rose to 7g/dl. Another bag was transfused on the 10th of July.

Past history: 

She received blood transfusions in 2018 for low Hb levels.

She is not a known case of HTN, DM, TB, asthma, epilepsy, CAD, CVA or thyroid disorders.

Personal history:

Diet: mixed

Appetite: normal

Sleep: adequate

Bowel and bladder: normal

No known allergies 

No addictions

Menstrual history:

Menarche attained at 14 years

Cycles: regular, once in 28 days

Flow lasting 5 days, normal amount, no clots.

Pain during first 2 days

Family history:

Not significant

General Examination:

Patient is conscious, coherent and cooperative.

Pallor is present

No icterus, cyanosis, clubbing, koilonychia, generalised lymphadenopathy or pedal edema is seen.

Weight: 40kg

Height: 5ft

BMI: 17.3 

Vitals:

PR: 100bpm

Rr: 16 cpm

Bp: 110/80 mmHg

Temperature: afebrile 

Systemic examination:

CNS:

Speech: normal
No signs of meningeal irritation
Motor & sensory system: normal
Cranial nerves: intact

CVS:

S1, S2 were heard

No Murmurs
No thrills

Respiratory system:
Position of Trachea: central
BAE: present
NVBS heard
No added sounds

Per Abdomen:
Soft, non tender
Hernial orifices are normal
No palpable masses
Bowel sounds heard

Investigations: