A 44 yr old female came with c/o generalized weakness

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Here is a case i have seen:

Pt presented to opd with c/o Generalized weakness.

A 44 yr old female who was apparently asymptomatic 1 yr back then developed pain in the legs(dragging type) ,which is a/w generalized weakness and shortness of breath.

The pain in the legs were aggravated during the last 2 months ,at the same time patient developed sudden diminision of vision in left eye,where they visited the local ophthalmologist treated with topical drugs.patient was referred to general physician in view of generalized weakness 

The treating physician found hb  of 3.2 g/dl for which he was referred to kims for further evaluation.

H/o headache occasionally over temporal region

H/o loss of appetite since 10 days,h/o occasional nausea

H/o surgery to the spine (in v/o disc prolapse) 4 yrs back

h/o hypothyroidism detected 3 days back (on levothyroxine)

No h/o palpitations,giddiness,pedal edema

No h/o HTN,DM,epilepsy,TB,Asthma 

Family history: not significant 

Personal history:

Diet:mixed

Appetite:decreased since 10 days

Sleep:adequate 

Bowel and bladder:regular

General examination 

Vitals:

Temp: afebrile

Bp:130/90

Pulse:74bpm

RR:18cpm

Pallor: present

No cyanosis, clubbing, koilonychia, lymphadenopathy,pedal edema

Systemic examination 

RESPIRTORY SYSTEM 

B/l air entry present

Normal vesicular breath sounds

No added sounds

CVS

S1S2 heard

No murmurs

PER ABDOMEN

Shape- elliptical 

No local raise of temperature,tenderness

No organomegaly,

Bowel sounds -present

CNS EXAMINATION 

Higher mental functions normal

Sensory and motor system- intact

Reflexes- intact

Cranial nerves- intact 

 

Hemogram done after blood transfusion on 11/9/2020

Second blood transfusion done on 13/9/2020

Diagnosis:Iron deficiency anemia?nutritional

Treatment given:

1)Two blood transfusions done

2) tab orofer xt po/od

3) tab mvt po/od