45year old female with generalised weakness ,fatigue and headache

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CASE SCENARIO:

A 45yr old female patient came with complaints of  generalised weakness and headche, fatigue   since 3 months 

HISTORY OF PRESENTING ILLNESS: 

The patient was apparently asymptomatic 2 years back and then she had

• heavy menstrual bleeding and prolonged duration of period for 7days for every 28days of cycle

( previously it was 3days for every 28days of cycle ),  with no h/o passage of clots

• diminished vision for past 1year,

•then developed Generalised weakness and easy fatigability from 3 months 

•headche from 3 months  of frontal site subsided on medication. 

•She visited local hospital  15 days back  with the similar complaints on investigations Hb was 5.5g/dl diagnosed anemia and had blood transfusions - orofer infusions 200mg  for 6 times ( 1200mg) 15 days back.

HISTORY OF PAST ILLNESS:

N/k/o HTN,DM,TB,epilepsy,asthma,thyroid.

TREATMENT HISTORY:

For ANEMIA  blood transfusions done

orofer infusions 200mg  for 6 times ( 1200mg) 15 days back.

PERSONAL HISTORY:

Married

Occupation: vender in chicken shop

Diet: Mixed , Non vegetarian 

Appetite: decreased 

Sleep: inadequate 

Bowels: Regular 

Known Allergies: No

No addictions.

FAMILY HISTORY:

Mother k/o diabetes mellitus since 40yrs.

MENSTRUAL HISTORY:

Age of menarche-15yrs

Menstrual cycle- past:3/28, present :7to8/28

LMP-20/7/22

OBSTETRICS HISTORY:

Age of marriage-19yrs

Para-P2L2

No of live births-2

No abortions

3rd degree consanguinous marriage. 

BIRTH HISTORY 

full term normal delivery 

IMMUNIZATION STATUS:up to mark

GENERAL EXAMINATION

Patient is conscious and coherent

Moderate built and moderately nourished

Well oriented to time, place and person. pallor present 

 NoIcterus 

No cyanosis 

No clubbing 

No lymphadenopathy

Oedema of feet -no

No malnutrition 

No dehydration 

VITALS:

Temperature-afebrile

Pulse rate- 82/min

Respiratory rate- 16/min

BP- 120/80mmHg

SPO2 - 98% 

GRBS- 120mg%

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Thrills: No

Cardiac sounds: S1 , S2

Cardiac murmurs: No

RESPIRATORY SYSTEM

Dyspnoea:No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

Adventitious sounds : No

ABDOMEN

Shape - Scaphoid 

No tenderness, palpable mass, 

No Fluid 

No bruits

CENTRAL NERVOUS SYSTEM

Level of consciousness - consciouss

Speech - Normal

No signs of meningeal irritation

Cranial nerves - Normal

No motor or sensory deficit

Reflexes 

        Biceps  Triceps  Supinator  Knee  Ankle  

Right    +      +            +          +       +           

Left      +          +             +            +        +

     

PROVISIONAL DIAGNOSIS:

CHRONIC ANEMIA

 

Investigations:

DIAGNOSIS:

Chronic anemia due to blood loss.

Intramural fibroids