30 F with complaints of SOB on and off since 10 years, generalised weakness

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input 

30 year old female patient came to opd with complaints of fatigue , weakness and SOB since 12 years
HOPI
patient is apparently asymptomatic 12 years then she developed SOB (grade 2-3)on and off associated with
fatigue and weakness
C/o cold intolerance
C/o constipation (once in 2-3 days)
C/o weight fluctuation since 1 year
C/o burning micturition 
C/o malena since 3 months
C/o bloating
No H/o fever,nausea, vomiting,cold, cough 

COURSE OF ILLNESS
Past history
N/k/c/o HTN,DM,CAD,asthma,TB, epilepsy,CVA
H/o 2 units of blood transfusion done 12 years ago during 2nd pregnancy antenatally, Allergic reaction noted during 1st unit of transfusion and medication given
Tubectomy done 10 years back

Personal history: 
Diet mixed 
Appetite decreased 
Sleep inaequate
Bowel and bladder irregular 
No addictions 

No significant family history

Menstrual history
Age of menarche - 13 years
Menstrual cycle - 7-8/30
Uses 1 pad per day


General examination

Patient is c/c/c well oriented to time place person 
Moderately built and nourished 

Pallor present 

No signs of icterus cyanosis clubbing lymphadenopathy generalized edema

Vitals : 

Temperature 97.5
PR 83 bpm
 BP 130/80 mmhg
RR 21cpm
Spo2 98 at ra 

Systemic examination

CVS - S1 S2 Heard no murmurs 

RS - BAE + NVBS 

CNS : NFND 

P/A : soft,non tender

Provisional diagnosis
Anemia under evaluation

Investigations

USG
impression
E/o 60x45mm fibroid noted in the posterior myometrium of the uterus
Grade 1 fatty liver

FINAL DIAGNOSIS
Iron deficiency Anemia 2° to blood loss with dilated cardiomyopathy with intramural fibroid

TREATMENT
TAB OROFER XT PO/OD
1 UNIT OF PRBC TRANSFUSION DONE 


 











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