45 years old female with shortness of breath
January 06,2023.
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A 45 year old female patient presented to the opd with chief complaints of shortness of breath from 15 days who is a house maker by occupation
HISTORY OF PRESENT 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 and cold temperature(class 2 NYHA) and relieved on rest. Within few days of onset of her symptoms the shortness of breath has progressed to class 4 NYHA which is shortness of breath at rest. So she went to a local hospital where she took a blood test and found her hemoglobin levels to be very low(3.6gm/dl) and she was referred to our hospital for blood transfusion
H/O cough since 15 days which is associated with mucous which is yellowish white in color and intermittent in nature
No history of any bleedings, weight loss, burning micturition, vomitings, loss of sensation and change in appetite, chest pain, GI bleeding.
No history of weight changes
Past history:-
No history of hypertension, epilepsy, asthma, coronary artery disease or chronic kidney disease.
Personal history:-
FAMILY HISTORY-
Not significant
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 HISTORY-
She had a previous blood transfusion of 3 packs 1 yr back
Medroxy progestrone acetate once daily for 2 months
Dexorange from last 4 days
SURGICAL HISTORY-
She had previous two LSCS and tubectomy done.
GENERAL EXAMINATION-
I have examined the patient in a well lit room with a female nurse ,Patient is conscious coherent and co operative well oriented to time place and person.
She's moderately built and nourished.
Pallor - Present
Icterus - AbsentClubbing- Absent
Cyanosis- Absent
Lymphadenopathy- Absent
Edema - Bilateral on lower limbs till knees pitting type
VITALS-
Temperature afebrile
Respiratory rate 30cpm
Pulse rate 118bpm
Blood pressure 110/70mmHg
Spo2 97%
SYSTEMIC EXAMINATION-
CVS- S1 S2 heard No murmurs JVP raised
RS- Normal vesicular breath sounds
P/A- Soft non tender no organomegaly C section scar visible.
CNS - No focal neurological deficit.
PROVISIONAL DIAGNOSIS-
Anemia leading to secondary right heart failure
INVESTIGATIONS-
06/01/22 no test reports
05/01/22
4/1/23
Previous
PROBABLE DIAGNOSIS-
Dimorphic anemia with Heart failure.
TREATMENT-
Fluid restriction < 1.5 lit/day
1 pack of PRBC was done after injecting lasix 20mg
Inj lasix
Inj ecospril
Tab carvediol
Inj Vitcofol
Tab orofer
FAMILY HISTORY-
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 HISTORY-
She had a previous blood transfusion of 3 packs 1 yr back
Medroxy progestrone acetate once daily for 2 months
Dexorange from last 4 days
SURGICAL HISTORY-
She had previous two LSCS and tubectomy done.
GENERAL EXAMINATION-
I have examined the patient in a well lit room with a female nurse ,Patient is conscious coherent and co operative well oriented to time place and person.
She's moderately built and nourished.
Clubbing- Absent
Cyanosis- Absent
Lymphadenopathy- Absent
Edema - Bilateral on lower limbs till knees pitting type
VITALS-
Temperature afebrile
Respiratory rate 30cpm
Pulse rate 118bpm
Blood pressure 110/70mmHg
Spo2 97%
SYSTEMIC EXAMINATION-
CVS- S1 S2 heard No murmurs JVP raised
RS- Normal vesicular breath sounds
P/A- Soft non tender no organomegaly C section scar visible.
CNS - No focal neurological deficit.
PROVISIONAL DIAGNOSIS-
Anemia leading to secondary right heart failure
INVESTIGATIONS-
06/01/22 no test reports
05/01/22
4/1/23
Previous
PROBABLE DIAGNOSIS-
Dimorphic anemia with Heart failure.
TREATMENT-
Fluid restriction < 1.5 lit/day
1 pack of PRBC was done after injecting lasix 20mg
Inj lasix
Inj ecospril
Tab carvediol
Inj Vitcofol
Tab orofer
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