17 YEAR OLD FEMALE WITH ANAEMIA.

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This 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.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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.


 17 year old female came to the casualty with chief complaints of:

-Generalized weakness since 1 month
-Headache since 1 month
-SOB on exertion since 20 days
-C/O nausea since 10 days
-Low grade fever on and off since 5 days
-Productive cough and cold since 5 days

History of present illness:

Patient was apparently asymptomatic 1 year ago
then she had fever for which she went to a local hospital,was told to have Hb-6 g/dl and was advised for diet modification and oral medication. 
Patient was fine till 1 month back,then she developed generalized weakness,headache. 
SOB on exertion since 20 days.
C/O nausea since 10 days for which she went to a local RMP and was given oral iron syrup-following which stools turned black.
C/O hypomenorrhoea-last menses in October 2021.
No C/O hematuria,malena,hematemesis,menorrhagia. 

Past history:

No H/O  DM, HTN, CAD, epilepsy.

Personal history:

Diet-mixed
Appetite-normal
Sleep-adequate 
Bowel and bladder movements-regular 
No addictions

Menstrual history:

Last menses-october 2021
Irregular menses once in 4 months

General examination:

Patient is conscious, coherent, cooperative and well oriented with place, person and time. 

Pallor-present 
No icterus,cyanosis,clubbing,lymphadenopathy, edema

Vitals on admission:

Temperature-98.4 F
PR-125 bpm
RR-18 cpm
BP-140/80 mmhg
Sp02-98% @ RA

Systemic examination:

CVS-S1,S2 heard 
RS-BAE present, NVBS heard
P/A-soft,non-tender
CNS-No FND

Investigations:

Hemogram:

ECG:

2D Echo:

CUE:


USG Report:

Provisional diagnosis:

Anaemia under evaluation 


Treatment:

Blood transfusion (PRBC) 
Inj. Nervijen 1amp + 100ml NS IV OD 
Inj. Vitocofol 1cc IM OD
Tab. Orofer-XT 
Inj. Optineurin 1amp + 100ml NS IV OD
GRBS 12th hrly
W/F SOB



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