45 year-old male with generalised weakness

 

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A 45 year old male from Miryalaguda, farmer by occupation came to the OPD with complaints of •generalised weakness 

•mild shortness of breath since 5 months. 

HOPI- 

•Patient was apparently asymptomatic 5 months back, then he developed fatigue and weakness on continued exertion.

• Two episodes of blood loss while passing stools, 6 months back. 

•h/o shortness of breath since 5 months, not associated with palpitations, orthopnea, pnd. 

Past History-

Not a known case of DM, HTN, asthma, TB, CVD, epilepsy 

Personal History-

Diet: Mixed (more vegetables than meat, and fish)

Appetite: Adequate 

Sleep: disturbed sleep due to leg pain 

Bowel and bladder: normal 

Addictions: Smoking since 25 years (10/day)

Allergies: None 

Family History- 

Not relevant 

Treatment History- 

Not significant 

->GENERAL EXAMINATION:

Patient is examined in a well lit room after taking informed consent. 

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

Pallor: present

Icterus: absent 

Clubbing: absent 

Koilonychia: absent 

Lymphadenopathy: absent 

Pedal edema: absent 

Vitals 

PR: 96bpm

BP: 110/60

->SYSTEMIC EXAMMINATION: 

CVS : S1,S2 +, No added sounds.

R/S : BAE+, Clear.

P/A : Soft, Non tender, No organomegaly.

CNS: NFND

Investigations:

Provisional Diagnosis: 

Microcytic hypochromic anemia secondary to two episodes of blood loss.

Treatment: 

Blood transfusion on day of admission 

10 PRBC on 18/7/23

Pantop 40mg

OROFER XT 

NEUROBION FORTE 

INJ VITCOFOL