42 year old female with sob and generalised weakness
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CHEIF COMPLAINTS:
A 42 year old female came from chityala with the cheif complaints sob and generalised weakness since 1 month.
HISTORY OF PRESENTING ILLNESS:
Patent was apparently asymptomatic 5 years back (2017)then she developed chest pain and sob on exertion which was sudden in onset for which she went to hospital and was found to anemic for which she had underwent 1 packet of red blood cell transfusion and after that she took oral iron for one 1 year and then stopped .
And after 4 years she came with the complaints of headache , vomiting and giddiness and was on conservative treatment she had one more packet rbc transfusion in nlg government hospital as she couldn't afford here.
Now she complaints of pain in the left ear and discharge form left Ear since 1 month and was was found out to be otomycosis and is on medication.
HER DAILY ROUTINE:She used to wake up in the morning at around 5 AM.she used to do all her household work and gets fresh up.she used to cook food for her daughter and sends her to the school.she has a cup of tea with biscuits and goes to work at 7 AM(hotel worker-floor cleaning,table cleaning and cleaning utensils in hotel).she has her breakfast at 11 AM in the hotel itself and continues her work.she has her lunch at 3 PM again in hotel.she returns home in the evening at around 6 PM and cooks food at home for dinner.she has her dinner at 8-9 PM and goes to bed at 10 PM.
PAST HISTORY:
No h/o diabetes,HTN,asthma,epilepsy.thyroid abnormalites and previous h/o surgeries.H/o of blood transfusion 2 times.
PERSONAL HISTORY:
Diet:vegeterian (also eats egg)
apetite:nornmal
bowel and bladder:regular
sleep:adequate
addictions:no addictions.
FAMILY HISTORY: No H/o similar complaints in the family.
MENSTRUAL HISTORY:
Regular menses-3 days, no clots , normal flow.
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative.
Patient is lean and malnourished
Well oriented to time place and person.
Pallor present.
Treatment:
CIPROFLOXACIN :500MG
TAB PANTOP 40MG
TAB: LEVOCET
CANDID EAR DROPS
PLAN PRBC TRANSFUSION
INJ:NERVIGEN 1 AMP +100ML NS.
IRON SUCROSE 200 MG IN 100 ML NS
Follow up on the 2nd day
S:-
Sob reduced
O:-
Pt is c/c/c
Bp:- 140/90 mmhg
Pr:- 80bpm
Cvs:- s1s2 +
R/s :- BLAE+
P/A :- soft non tender
A :- Anemia under evaluation with left ear otomycosis
P:-
-Tab. Ciprofloxacin 500mg po/bd
-tab. Pan 40 mg po/od /bbf
-tab. Levocet 5 mg po/hs
- Candid ear drops
3 drops - 3 drops - 3 drops
- plan 1 unit Rbc transfusion
Inj. Nervigen 1 amp. In 100 ml Ns iv/od
- Iron sucrose 200mg in100 ml NS IV/STAT
Follow up on the 3rd day
S:-
Sob reduced
O:-
Pt is c/c/c
Bp:- 140/90 mmhg
Pr:- 80bpm
Cvs:- s1s2 +
R/s :- BLAE+
P/A :- soft non tender
A :- Anemia under evaluation with left ear otomycosis
P:-
-Tab. Ciprofloxacin 500mg po/bd
-tab. Pan 40 mg po/od /bbf
-tab. Levocet 5 mg po/hs
- Candid ear drops
3 drops - 3 drops - 3 drops
- plan 1 unit Rbc transfusion
Inj. Nervigen 1 amp. In 100 ml Ns iv/od
- Iron sucrose 200mg in100 ml NS IV/STAT
Follow up on the 4th day
S:-
Shortness of breath subsided
O:-
Pt is c/c/c
Bp:- 140/90 mmhg
Pr:- 80bpm
Cvs:- s1s2 +
R/s :- BLAE+
P/A :- soft non tender
A :- Anemia under evaluation with post transfusion reaction aki and hepatic failure with left ear otomycosis
P:-
-tab. Levocet 5 mg po/hs
- Candid ear drops
3 drops - 3 drops - 3 drops
-Inj.Nervigen 1amp in 100ml Ns/iv/od
FOLLOW UP ON 5TH DAY
S:-
Shortness of breath subsided
O:-
Pt is c/c/c
Bp:- 140/90 mmhg
Pr:- 80bpm
Cvs:- s1s2 +
R/s :- BLAE+
P/A :- soft non tender
A :- Anemia under evaluation with post transfusion reaction aki and hepatic failure with left ear otomycosis
P:-
-tab. Levocet 5 mg po/hs
- Candid ear drops
3 drops - 3 drops - 3 drops
-Inj.Nervigen 1amp in 100ml Ns/iv/od
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