general medicine

Case in brief
A 48yr old female,who is a daily wage worker by occupation came to opd with,
Chief complaints:-
Facial puffiness
Weakness
SOB while walking 

History of presenting illness
Patient was apparently aysmptomatic 1week back ,then developed facial puffiness and weakness



History of past illness 

She had undergone bilateral salpingo-oophorectomy surgery
Not a k/c/o diabetes/hypertension/asthma/CAD /TB 

Treatment history
She was not on any medication 

Family history
There is no significant family history 

Personal history 

• Mixed diet 
• Normal appetite
• Regular bowels
• No known allergies
• Adequate sleep
• Habits- occasional alcoholic - 500ml 

Daily routine
She generally wakes up at 6:00am and have curd rice for breakfast and goes for work at 9:00am and at 2:00 pm she will have lunch(rice and vegetable curry) and get backs home by 6:30 and the  she will have her dinner by 9:00 pm and goes to sleep. 

GENERAL EXAMINATION 

On Examination,
•  Patient is conscious,coherent,co - operative and well Oriented to time,place and person.
• There are signs of pallor and clubbing
• Pedal edema -grade 1


• There are no signs of:- 

Icterus,cyanosis, Lymphadenopathy 

VITALS
Temperature: 99°F
PR: 86bpm
BP:118/56mmHg
RR:20/min
RBS-165mg/dl 

Systemic examination 

C VS:
No thrills 

S1 and S2 + 

NO murmurs 

Respiratory system 

NO Dyspnoea 

NOWheeze 

Trachea is centrally located 

Abdomen 

soft and non tender 

NO palpable Mass 

Liver and Spleen are not palpable 

CNS
Conscious 
Normal speech 
No neck rigidity
Motor and sensory sytem intact 

Investigations
Hb after blood transfusion-6.9
USG ABDOMEN
Grade 1 fatty liver with mild hepatomegaly
Provisional diagnosis
Chronic anaemia


Treatment
29/7/22
Blood transfusion was done at 9:30am.
Hb after transfusion-6.9gm/dl 

30/7/22
Tab.OROFER XT  OD 
Inj.Nervijen  IM /OD -9:00 am
Tab.lasix 40mg od 

1/8/22
Tab.OROFER XT  OD 
Inj.Nervijen  IM /OD -9:00 am
Tab.lasix 40mg od

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