1601006159- SHORT CASE

CASE:

A 56yr old male , sales manager by occupation , resident of miryalaguda ,came to the opd with cheif complaints of easy fatiguability on excertion since 30 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 30 days back then he developed fatigue on excertion which was insidious in onset , gradually progressed to the present stage. ( He was able to walk 500m initially.... But now he can only walk 100m ) which was associated with Dyspnea on excertion , palpitations and body pains.

No complaints of - chest pain , cough , fever , hematuria .

PAST HISTORY:

No H/o DM , HTN, Asthma, Epilepsy, CAD

FAMILY HISTORY:

No significant history

PERSONAL HISTORY:

Diet - Mixed
Appetite - Normal
Sleep - Adequate
B&B - regular
No Addictions

GENERAL EXAMINATION:

Patient was conscious coherent and cooperative 

Moderatly built and nourished

VITALS:

Pulse - 94 bpm
Regular
Normal volume 
BP - 100/70 mm hg
Respiratory rate - 29 cpm 

OTHER SIGNS:

Pallor - Present

Icterus - absent 

Cynosis - absent 

Clubbing - absent 

Koilonychia - Absent

Lymphadenopathy - absent 

Edema - absent 

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

S1 S2 Heard 
No murmurs
Apex beat heard at left 5th ICS

RESPIRATORY SYSTEM:

Normal Vesicular Breath Sounds

CNS

All nerves are intact


GIT:

No hepatospleenomegaly
Bowel sounds heard

DIFFERENTIAL DIAGNOSIS:

Nutritional Anemia
Iron deficiency anemia

PROVISIONAL DIAGNOSIS:

Iron deficiency Anemia


INVESTIGATION:

-Complete Blood picture
-Stool Examination ( occult blood )
-Urine Examination

TREATMENT - 
 Diett Rich in Iron
 Ferrous Sulphate 200mg OD

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