Final practical long case

A 40 yr old female with severe anaemia

 February 07, 2022


A 40 yr old unmarried female c/o
Generalized weakness since 1yr
Decreased appetite since 1 yr
Bleeding PV since 4 days
She is a second born child of her parents ( 3rd degree consanguinous marriage)

HISTORY OF PRESENT ILLNESS:
Patient attained menarche at the age of 14, since then cycles were regular, with normal flow initially.
4-5 days /month, no clots, dysmenorrhea. 
LMP- 05/02/2022
But since 6 months she has increased bleeding during her cycles. 6months patient went to other private hospital where she was diagnosed with low Hb% and advised for blood transfusion which was not done and patient was not on any medication for anaemia.
HISTORY OF PAST ILLNESS:
Not a k/c/C/o DM, HTN, thyroid, epilepsy, asthma.
PERSONAL HISTORY:
Unmarried 
Occupation -11th standard 
Appetite decreased since 2ys only 1 meal /day
Non-vegetarian 
Bowels -constipation 
Micturation-normal 
No known allergies 
No addictions 

General examination
Patient is c/c/c thin built and malnourished
Pallor ++



no icterus, cyanosis, clubbing, edema
Temp-Afebrile
PR - 108bpm
BP-100/60 mmHg
Spo2 99%
GRBS - 87mg/dl
SYSTEMIC EXAMINATION:
CVS
No thrills 
Cardiac sounds -s1,s2+
Cardiac murmurs-no 
Respiratory system-
Dysponea-no 
Wheeze-no 
Position of trachea-central 
Breath sounds -vesicular

ABDOMEN

Shape of abdomen-scaphoid 

No tenderness 

No palpable mass 

Hernial orifices-normal 

No free fluid 

No bruits 

Liver ,spleen-not palpable 

Bowel sounds -yes 

CNS:

Conscious 

Normal speech 

No neck stiffness 

No kernings signs 

Cranial nerves ,motor and sensory system,glasgow scale -normal .

PT - c/c non Co operative
PROVISIONAL DIAGNOSIS:
Anaemia secondary to blood loss 

Investigations  
07/02/2022
ECG

08/02/22



               2decho
            Neck 

          Abdomen 

DIAGNOSIS:
Bicytopenia under evaluation.
Rx
 1.inj TRANEXA 500MG IV stat
 2.inj pantop 40 mg iv/od
 3.inj zofer 4 mg iv/sos
 4. Plan for 1unit PRBC transfusion
 5. Monitor vitals 4th hrly
 6. I/o charting



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