1801006032 SHORT CASE

28 years old male presented to OPD

CHIEF COMPLAINTS:

1)Generalised weakness since  2 weeks

2)Shortness of breath since 2 weeks

3)Easy fatigability since 2 weeks


HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2 weeks back then he developed generalised weakness insidious in onset, gradually progressive

Shortness of breath of grade 2 which is insidious onset, which is grade 2 (NYHA classification) - slight limitation of activity -ordinary activity results in fatigue) ,no aggrevating and no relieving factors

Easy fatigability present

No c/o fever, nausea, vomiting, chest pain, pain abdomen, blood in stools, loose stools, sweating

PAST HISTORY: 

Not a known case of DM/HTN/TB/Epilepsy/Thyroid abnormalities/Asthma

PERSONAL HISTORY:

Decreased appetite since 5-6 months

Takes vegetarian diet

Bowels and bladder habits are regular

sleep is regular

No addictions 

FAMILY HISTORY: 

No significant family history

TREATMENT HISTORY: 

No significant history

GENERAL EXAMINATION: 

Patient is conscious, coherent, cooperative 

*Pallor is present

No signs of icterus,cyanosis, clubbing,
 lymphadenopathy, pedal edema

Vitals:

Temp: afebrile

PR: 90 bpm

RR: 22 /min

BP: 140/80 mm hg


Systemic examination:


CVS: S1 S2 heard, No Murmur 

RS: Bilateral air entry present

CNS: No focal neurological deficit 

Per Abdomen : soft, non tender, no hepatosplenomegaly

Bowel sounds heard


INVESTIGATIONS:

Peripheral smear::


Serum electrolytes



Serum creatinine:



Blood urea:



Serum iron ::


Complete Urine Examination::



LFT::

ECG::

Chest x-ray ::


Provisional Diagnosis: 

Anemia secondary to vitamin B12 deficiency and iron deficiency (dimorphic anemia)

TREATMENT :

Inj. VITCOFOL 1000mg/IM/OD

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