40M,Easy fatigability 1yr


A 40 year old male came with complaints of easy fatigability since 1 year (on & off)
Shortness of breath since 5-6 months
HOPI:
Pt was apparently asymptomatic 1 year back he then noticed having easy fatigability - feeling tired on doing minimal work  insidious in onset and gradually progressive.
C/o shortness of breath since 5-6months insidious in onset and gradually progressive grade ll to grade lll (now)
C/o decreased appetite since 1 month, Normal urine output
C/o blood in stools (on & off) since 1 year with fresh blood streaks.
No h/o constipation, difficulty on passing stools
No c/o fever ,pain abdomen,cold,cough, burning micturition, vomitings,nausea,blood in urine.
No h/o chest pain,orthopnea,PND, palpitations, giddiness, sweating.
C/o generalized weakness of body since
 5-6 months.
Not a k/c/o DM,HTN,CVA,CAD, Epilepsy, Thyroid diseases, Bronchial Asthma.
Personal history:
Ocassionally Alcoholic and stopped 10years back 
Tobacco smoking since 20 years
No h/o blood transfusion in the past

Personal History- 
Diet- Mixed
Appetite- Decreased since 1 month
Bowel & Bladder Movements-H
Sleep - Adequate
Addictions - Chronic Alcoholic Since past 40 years consumed around 90 to 120ml/day
 H/O Smoking since past 20yrs 

Family history- Not Significant

Vitals-
TEMP: Afebrile 
BP: 110/60mmHg
PR: 96 bpm
RR- 18cpm
Spo2- 98% @RA

Systemic Examination:
CVS:
Inspection
Chest wall is bilaterally symmetrical.
No precordial bulge is seen 
Palpation
JVP- Normal
Apex beat -felt in the left 5th intercoastal space in the mid clavicular line 
Auscaltation-
S1&S2 are heard,no murmur found.

RESPIRATORY SYSTEM

Position of trachea- central
Bilateral air entry, normal vesicular breath sounds are heard.
No added sounds

CNS

Patient is conscious ,coherent and co operative , well oriented to time and space.
Speech normal.
No signs of meningeal irritation.
Motor and sensory system- Normal
Reflexes - present
Cranial nerves - intact
 
Provisional diagnosis : Anemia under evaluation 



Stool for occult blood 







Serology:

Chest xray 

2D -ECHO

Diagnosis: Iron deficiency Anemia

Treatment:

1.TAB.PAN.40Mg PO/OD
2.TAB.OROFER-XT PO/BD
3.TAB.NEUROBION FORTE PO/OD

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