24/F chronic anemia 2° dietary iron deficiency ?
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I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation
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A 24 year old woman Ms.A a student by occupation and a resident of west bengal came to the medicine opd with c/o
-nausea and dizziness since 4 months
history of presenting illness
patient was apparently asymptomatic 7 years ago , when she developed nausea and dizziness it was aggravated on walking and relieved on taking rest , she also noticed hairfall and dry skin , after a routine blood investigation it was discovered that her Hb was 7.2 gm/dl for which she was treated by giving iron injections over the course of one week , patient has been asymptomatic since then , 4 months ago she gave history of similar complains associated with SOB grade 3 according to NYDA classification .
history of past illness
k/c/o Diabetes Mellitus sibce 1 year
n/k/c/o HTN , TB , asthma
surgical history
h/o cholecystectomy 4 months back due to cholithiasis
treatment history
metformin tablets once a day since one year
-before breakfast : lipoglobin -HP
-after breakfast Diapride M1
-before dinner: lipoglobin -HP
-after dinner: vildagliptin tablets OP and folvite
menstrual history
age at menarch : 11 years
regular cycles 5/30
3 pads per day
associated with clots 1cm * 0.5cm
associated with pain
LMP : 3/05/2023
-IRREGULAR PERIODS SINCE 2 MONTHS ; hypomenorrhea , oligomenorhhea
family history
mother is a known case of hypothyroid
personal history
diet : mixed
appetite : loss of appetite since
sleep : adequate
bowel and bladder : normal and regular
occasionally consumes alcohol
no known allergies
GENERAL EXAMINATION
patient was c/c/c oriented to space , time and person
weight : 52kg
height : 5 feet
months
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