59 K. Rithika Vasantha

E-LOG GENERAL MEDICINE
Hi, This is Rithika, a third semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them. 


A 17 YEAR OLD GIRL WITH SEVERE IRON DEFICIENCY ANAEMIA

Chief complaints:

• SOB on exertion since 2 months
• Generalized weakness

HOPI :

• Patient was apparently asymptomatic till 2 months ago, and then developed SOB whenever she does some work. ( Recently, on Sunday she went to a local hospital to get her covid vaccine, where she got her CBP done and got to know that she has Hb of 2gm/dl. ) 
• She complaints of on and off chest pain for 2 months. 
• She complaints of generalized weakness too. 
• Complaints of palpitations since 2 mnths
• No h/o melena, hemorrhoids
• Has h/o pica in childhood
• She attained menarche 6 mnths ago, 3-5 days/30 days.... 3-4 pads /day, fully soaked ; no h/o severe pain and clots. 

Past history :

• She had similar complaints since her 9th grade. So, she is on iron tablets, which she takes very irregularly. 
• She has no h/o previous blood transfusions and surgeries. 
• Not a k/c/o DM, HTN, TB, asthma, cancer, epilepsy. 

Personal history:

• She is unmarried. 
• She has decreased appetite. 
• Has h/o constipation
• Has normal micturition. 
• No known allergies and addictions

Family history:

• Has no family h/o DM, HTN, TB, thyroid, cancers, epilepsy. 

Menstrual history:

• Age of menarche - 16 yrs
• 3-5 days/30 days.... 3-4 pads /day, fully soaked ; no h/o severe pain and clots. 

General Examination :

• Pallor - present




• Cyanosis - absent
• No lymphadenopathy, clubbing, dehydration, oedema. 

Vitals :

• BP - 110/50 mmHg
• Temp. - 98.6°
• SpO2 - 94%
• RR - 18 cycles/min
• PR - 90 bpm

Systemic Examination:

CVS:
• S1, S2 heard
• No thrills and cardiac murmurs

RESPIRATORY SYSTEM:
• No dyspnoea, wheezing
• Postion of trachea - 
• Breath sounds - Vesicular

ABDOMEN:
• No tenderness, palpable mass, bruits
• No palpable liver and 

CNS:
• Conscious and coherent
• Speech - normal
• No signs of meningeal irritation
• Glass gow coma scale - 15/15

PROVISIONAL DIAGNOSIS:

      IRON DEFICIENCY ANAEMIA

Investigations :

Treatment:

• Inj. Nervigen
• Tab. Orofer
• Tab. Matilda Forte
• Packed RBCs transfusion

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