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1601006192 SHORT CASE

 SHORT CASE : A 56-YEAR-OLD GENTLEMAN WITH EASY FATIGUABILITY ON EXERTION.



 HALL TICKET NUMBER : 1601006192





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


HISTORY OF PRESENTING ILLNESS:

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

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


PAST HISTORY:

No H/o DM , HTN, Asthma, 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 

Moderately 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 

Cyanosis - 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 hepato-spleenomegaly
Bowel sounds heard


DIFFERENTIAL DIAGNOSIS:

Nutritional Anaemia
Iron deficiency anaemia


PROVISIONAL DIAGNOSIS:

Iron deficiency Anaemia.


INVESTIGATION:

-Complete Blood picture
-Stool Examination 
-Urine Examination






TREATMENT - 

Suggest the patient to go on a diet Rich in Iron

Ferrous Sulphate 200mg OD

Total dose infusion can be done 

IM route of ferrous sucrose is also available 

In extreme anemia complicated with hemodynamic instability blood transusions can be done.

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