A 45 years old with shortness of breath since 15 days
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Rajashekar Ponna
Roll no. 124
A 45 yr old female home maker by occupation came to opd with chief complaints of shortness of breath since 15 days
HISTORY OF PRESENTING ILLNESS-
Patient was apparently asymptomatic 15 days ago . Then she developed shortness of breath which was insidious in onset gradually progressive and aggravated on stress, work and cold temperatures (Class 2 NYHA ) and relieved on rest.Within to few days of onset of her shortness of breath it progressed to her unable to perform her daily activities( Class 3) so she went to local hospital were her haemoglobin levels were found to be low (3.6) and she was advised to our hospital for blood transfusion.
No history of weight loss ,burning micturation, vomitings, loss of sensations and change in appetite, chest pain , sudden grasping of air at night.
No history of any weight changes
STAY IN HOSPITAL-
She was transfused 1 pack of PRBC today
PAST HISTORY-
She had a previous blood transfusion of 3 packs 1 yr back since on her hospital visit for menoragghia she was found to be having low haemglobin
Not a known case of hypertension, diabetes, epilepsy ,aasthma, coronary artery disease or chronic kidney disease.
MENSTRUAL HISTORY-
Age of menarche 12 yrs
Previous cycles were 3/30 with no pain and clots
Since 1 yr she is having 5/20 with heavy menstrual bleeding with no pains and clots and she went to hospital and was diagnosed with fibroids and was advised hysterectomy and then on routine investigations because of her low hb surgery was postponed and she was given blood transfusions and her hb raised to 8 gm% which was not adequate for surgery and as she qas approaching menopause on advise of her relatives she didnt want surgery
DRUG/SURGICAL HISTORY-
Medroxy progestrone acetate once daily for 2 months
Dexorange from last 4 days
She had previous two LSCS and tubectomy done.
PERSONAL HISTORY-
Diet Mixed
Appetite normal
Bladder and bowel movements regular
Sleep adequate
Allergies none
Addictions none
FAMILY HISTORY-
Not significant
Clinical pictures
GENERAL EXAMINATION-
Patient is conscious coherent and co operative well oriented to time place and person moderately built and nourished
Pallor - Present
Icterus - Absent
Clubbing- Absent
Cyanosis- Absent
Lymphadenopathy- Absent
Edema - B/l on both lower limbs till knees pitting type
VITALS-
Temperature afebrile
Pulse rate 118
Blood pressure 110/70
Spo2 97%
Respiratory rate 18cpm
SYSTEMIC EXAMINATION-
CVS-
S1 S2 heard
No murmurs
JVP raised
RESPIRATORY SYSTEM-
Normal vesicular breath sounds
PER ABDOMEN-
Soft non tender
No organomegaly
C section scar visible.
CNS -
No focal neurological deficit.
PROVISIONAL DIAGNOSIS-
Low levels of heamoglobin - anemia leading to secondary right heart failure
03/01/2023
Treatment-
Fluid restriction < 1.5 lit/day
Tranfuse PRBC
Inj lasix
Inj escoripin
Tab carvediol
Inj vitcofol
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