1601006187 SHORT CASE

 

1601006187 SHORT CASE


A 56 year old male sales manager by occupation came to opd with 

CHIEF COMPLAINT 

Easy fatiguability since 30 days 

History of presenting illness 

patient was apparently asymptomatic 30 days back OK then he developed fatigue on exception which was insidious in onset gradually progressive to the present stage ( he was able to walk 500 metres initially but now he can only walk hundred metres) with was associated with dyspnea on exception and body pains 

No complaints of chest pain cough fever Easy fatiguability


PAST HISTORY 

No history of diabetes mellitus ,HTN,asthma,CAD


FAMILY HISTORY

Diet mixed

Appetite normal 

Sleep adequate 

B and b regular 

No addiction

GENERAL EXAMINATION 

Patient was conscious coherent cooperative moderately built moderately nourished

VITALS 

PULSE.94bpm

Blood pressure -100/70

Respirator rate-29cpm


OTHER SIGNS

Pallor - present 

Icterus absent 

Cyanosis absent

Koilonychia absent 

Lymphadenopathy absent 

Edema absent 

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

S1 s2 heard 

No murmurs 

Apes beat at left 5th ics 

RESPIRATORY SYSTEM 

No VESICULAR breath sounds 


CNS

All nerve intact

GIT 

No hepatospleenomegaly 

Bowel sounds heard 

 DIFFERENTIAL DIAGNOSIS

nutritional anemia 

PROVISIONAL DIAGNOSIS

Iron deficiency anemia 


INVESTIGATION 

-Complete blood picture 

Stool examinations

urine examination.













TREATMENT

Diet rich in iron 

Ferrous sulphate 200 mg OD

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