17 year old Female with generalized weakness since 3 years

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I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my cmpetancy i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

March 4 2022

Preity Yarlagadda

Roll no:145

CASE :

A 17year old female patient student by occupation came to the hospital in early march with

 chief complaints of

• Generalized weakness since 2 to3years.
• Since 2months she complaining of shortness of breath on exertion,palpitations,fatiguability.
• Episodes of chest pain on/off.

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 3years back then she developed generalized weakness.

She developed shortness of breath on exertion(climbing uphill), palpitations and then she visited the government hospital and the doctor suggested to take iron tablets and also suggested blood test to be done by looking at her eyes (pallor).she taken the medication irregularly.

Then she went to get COVID vaccination 2 days back where she got blood test done and she get to know her HB value is 2.3.

There is a history of pica since childhood.

There is no history of fever,blood in stools, hemorrhoids.

There is no history of jaundice in the past.

No history of blood loss.

No history of seizure attack.

PAST HISTORY:-

Not a k/c/o of DM,HTN,thyroid disorders,BA,TB,epilepsy

No history of blood transfusion inthe past

No history of past surgeries.

MENSTRUAL HISTORY:-

She attained Menarche at the age of 16years

Regular,4days /30day cycle

Uses 3pads/day

Not associated with pain,clots.

LMP:16/2/22

For 3months she has polymenorrhea she menstruates 4 days/15 day cycle

PERSONAL HISTORY:-

Appetite:Normal

Diet:Mixed

Sleep: Adequate

Bowel habits: constipation since 2 to 3months

Bladder habits:regular

No addictions

FAMILY HISTORY:-

No similar complaints in the family

GENERAL EXAMINATION:-

Patient is conscious , coherent and cooperative and well oriented to time place 

and person, 

Thin built and moderately nourished

Pallor- present

Icterus- Absent

Cyanosis- Absent

Clubbing- Absent

Lymphadenopathy- Absent

Edema: Absent

VITALS

TEMPERATURE: Afebrile

PULSE RATE:90 beats /min

RESPIRATORY RATE:18Cycles/min

BP:110/60mm of hg

SPO2:97% at room air

SYSTEMIC EXAMINATION

CVS

S1,S2 Sounds heard

No audible murmurs

Thrills:No

RESPIRATORY SYSTEM

Dyspnea is present

Position of trachea:central

Normal vesicular breath sounds are heard

No adventitious sounds 

P/A

Shape of abdomen :scaphoid

Soft and non tender abdomen

Spleen is palpable upto 5cms below the left costal margin

Bowel sounds heard

CNS EXAMINATION

Higher mental functions intact

Cranial nerve examination normal

INVESTIGATIONS

On 26-02-20

Hb: 2

TLC: 340

Peripheral smear: ANISOPOIKLOCYTOSIS WITH MICROCYTIC HYPOCHROMIC CELLS, TEARDROP CELLS, PENCIL FORMS, NORMOCYTE

Blood group: B+v

Rcc: 1

On 28-02-20

ESR: 

LF

TB : 0.98

DB : 0.2

SGOT : 2

SGPT: 1

ALP : 20

TP :7. 

Albumin : 4.

RF

Sr Urea : 1

Sr Crt : 0.

Uris acid : 2.

Na+ : 14

K+ : 4.

Cl- :10

Sr IRON : 50 (37-145

Sr ferritin : 1.3 (23.9-336.2

COLOUR DOPPLER 2D ECHO

USG

On 01-03-2022

Hb: 5

TLC: 250

Sr LDH: 24

ECG

On 02-03-2022

Hb: 4.8

TLC: 2300

On 03-03-2022

Hb: 7

TLC: 2600

On 05-03-2022

TREATMENT:-

1/03/2022:

1)Monitor vitals

2)Inj.Nervigen1amp in 100ml of NS i.v OD over 1hr

3)T.Orofer-XT OD

2/03/2022:

1)Inj.Nervigen 1amp in looml of NS OD

2)T.Orofer-XT

Given 2 Units of PRBC

3/03/2022:

1)Inj.Nervigen 1amp in 100ml of NS OD

2)T.Orofer-XT OD

3)T.Matilda forte OD

4/03/2022:

Inj.Nervigen 1amp in 100ml of NS OD

2)T. Orofer-XT OD

3)T.Matilda forte OD

5/03/2022:

1)Inj.Nervigen 1amp in 100ml of NS i.v OD

2)T.Orofer-XT OD

3)Monitor vitals

4)T.Neuroblan forte PO OD

5)T.I.D 826 mg

200mg given yesterday Iron sucrose