17yr old female with shortness of breath

 A 17 year old female patient came with chief complaints of shortness of breath on exertion since 2 months.


History of presenting illness

Patient was apparently asymptomatic 2 months ago then she developed shortness of breath on exertion ie; grade 2. She wanted to get covid vaccination 3 days back so she got blood investigations done. He had a hemoglobin 2.3gm/DL
She complains of having generalized weakness  and palpitations since 2 months
No meleana / hemorrhoids 
no past history of surgeries 
she attainment 1 year ago 
3-5  days /30 days , 2-3 pads/day
1 unit of pc RBC question on the day of admission and another was done on on 2/03/2022, no pain and clots 


 Past history

No / H/of similar complaints in the past 
no history of past blood transfusions 
not a known case of asthma hypertension TB epilepsy and diabetes

Personal history

Appetite:decreased
Diet:mixed 
Bowel and bladder movements:constipation

ON EXAMINATION:

Patient was conscious , coherent , cooperative 
pallor -  present



cyanosis, icterus , lymphadenopathy, edema  are absent


VITALS:

temp:97.3F
PR: 98 bpm
BP: 110/50 mm hg
RR:16 cpm
spo2 :99%


SYSTEMIC EXAMINATION 

CVS : s1 , s2 heard 
RS : bilateral air entry present
P/A : soft  and non tender 
spleen palpable in left hypochondriac region
CNS : no focal or neurological deficits
       

INVESTIGATIONS :- 

HB :2.3 gm/dl
TLC : 3,400 cells/cumm
PLT : 1.70 lakh cells/cu mm
anisopoikilocytosis with microcytic hypochromic , tear  drop RBCs
BGT : B positive 
reticulocyte count : 1%



1 /3/22 
hb : 5.1 g/dl 
TLC :  2500/mm3 
platelets : 1.5 lakhs /mm3 


PROVISIONAL DIAGNOSIS 

IRON DEFICIENCY ANEMIA



Treatment 

1) INJ NERVIGEN 1AMP IN 100 ML NS IV OD
2) TAB OROFER XT PO OD 
3) TAB MATIDA FORTE PO OD

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