A 45 ye old with shortness of breath since 15 days

 03 - January - 2022

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Khushi Tulsyan

Roll no. 75

A 45 yr old female resident of xyz home maker by occupation presented 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.

History of cough since 15 days which is mucus asssociated yellowish white in colour intermittent in nature.

No history of weight loss ,burning micturatio ,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 

Known diabetic since hospital admission.

Not a known case of hypertension, 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

INVESTIGATIONS-

Haemogram-

31/12-

On 3/1/23-

ECG-

31/12

2/1/23-

Retic count - 0.9 ( 0.5 - 2.5)

Serum iron - 42ug/dl (37-145)

Peripheral Smear -

CUE-

USG -

Doppler-

Serum electrolytes-

X ray-

Treatment-

Fluid restriction < 1.5 lit/day

Tranfuse PRBC

Inj lasix

Inj escoripin

Tab carvediol