17 year old female with anaemia

 17 year old female came to the casualty with chief complaints of:

  • Generalized weakness since 1 month
  • Headache since 1 month
  • SOB on exertion since 20 days
  • C/O nausea since 10 days
  • Low grade fever on and off since 5 days
  • Productive cough and cold since 5 days
History of present illness:
Patient was apparently asymptomatic 1 year ago
then she had fever for which she went to a local hospital,was told to have Hb-6 g/dl and was advised for diet modification and oral medication. 
Patient was fine till 1 month back,then she developed generalized weakness,headache. 
SOB on exertion since 20 days.
C/O nausea since 10 days for which she went to a local RMP and was given oral iron syrup-following which stools turned black.
No C/O hematuria,malena,hematemesis,menorrhagia. 
C/O hypomenorrhoea-last menses in October 2021.
Past history:
Not a k/c/o DM,HTN,CAD,epilepsy.
Personal history:
Diet-mixed
Appetite-normal
Sleep-adequate 
Boweland bladder movements-regular 
No addictions
Menstrual history:
Last menses-october 2021
Irregular menses once in 4 months
General examination:
Patient is conscious, coherent, cooperative. 
Pallor-present 
No icterus,cyanosis,clubbing,lymphadenopathy, edema.
Vitals on admission:
Temperature-98.4 F
PR-125 bpm
RR-18 cpm
BP-140/80 mmhg
Sp02-98% @ RA
Systemic examination:
CVS-S1,S2 heard 
RS-BAE present, NVBS heard
P/A-soft,non-tender
CNS-No FND
Investigations:

30/12/21
31/12/21(post blood transfusion)
Provisional diagnosis:
Severe anaemia(dimorphic) secondary to ?nutritional cause.


Comments

Popular Posts