Nagaiah
18 year old student came with the chief complaints of
Fatigue since 1 month
SOB on exertion and physical activity since 1 month ( Grade -3 )
She was unable to do work on exertion. H/o chest pain which was relieved at rest. Palpitations positive.
Pedal edema Grade - 1 since 7 days , Facial puffiness since 7 days , Nausea & Vomitings since 3 days associated with food particles & not associated with blood.
No h/o Abdominal pain , pale colored stools, blood in stools
H/o Tingling since 20 days observed at rest , no tingling at regular work
Age of menarche - 12 years , 3/30 , Normal flow , No clots
Dietary history - H/o taking food twice a day mostly pickles , She consumes all vegetables ( not adequate ) , Less fruit intake
PAST HISTORY - No DM , HTN , CAD , ASTHMA , TB
FAMILY HISTORY - NAD
PERSONAL HISTORY -
Appetite - Normal
Diet - Mixed
Bowel & Bladder - Regular
Sleep - Adequate
Addictions - None
GENERAL EXAMINATION :
Pallor - Present , Edema of feet - Present
No Icterus , Cyanosis , Clubbing , Lymphadenopathy
VITALS :
PR - 120 bpm
BP - 80/50 mmhg
RR - 21 cpm
TEMP - AFEBRILE
SYSTEMIC EXAMINATION :
CVS - PSM heard
RS - BAE
P/A - Soft , Non tender
CNS - NAD
PROVISIONAL DIAGNOSIS :
Anemia under evaluation , Microcytic Hypochromic , IDA??
INVESTIGATIONS :
TREATMENT :
1. Inj. Iron Sucrose 1 Amp in 100 ml NS IV /OD
2. Inj. Methylcobalamine 1000 micrograms in 100 ml NS IV / OD
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