1601006103 - Short Case

A 56yr old male sales manager by occupation resident of Miryalaguda came to the hospital with the chief complaints of easy fatiguability on excertion since 30 days.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 30 days back then he developed fatigue on excertion which was insidious in onset , gradually progressed to the present stage. (He was able to walk 500m initially but now he can only walk upto a distance of 100m ) which was associated with dyspnea on excertion , palpitations and body pains.
No complaints of - chest pain , cough , fever , hematuria .

PAST HISTORY:

 No H/o DM , HTN, Asthma, Epilepsy, CAD

 FAMILY HISTORY:

No significant history

PERSONAL HISTORY:
Diet - Mixed
Appetite - Normal
Sleep - Adequate
B&B - regular
No Addictions

GENERAL EXAMINATION:

Patient was conscious coherent and cooperative 
Moderatly built and nourished

VITALS:
Pulse - 94 bpm
Regular
Normal volume 
BP - 100/70 mm hg
Respiratory rate - 29 cpm 

OTHER SIGNS:
Pallor - Present
Icterus - absent 
Cynosis - absent 
Clubbing - absent 
Koilonychia - Present 
Lymphadenopathy - absent 
Edema - absent 

SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:

S1 S2 Heard 
No murmurs
Apex beat heard at left 5th ICS

RESPIRATORY SYSTEM:

Normal Vesicular Breath Sounds
CNS
All nerves are intact

GIT:

No hepatosplenomegaly
Bowel sounds heard

DIFFERENTIAL DIAGNOSIS:
Nutritional Anemia
Iron deficiency anemia

PROVISIONAL DIAGNOSIS:
Iron deficiency Anemia

INVESTIGATION:
-Complete Blood picture
-Stool Examination ( occult blood )
-Urine Examination

TREATMENT- 
 Diet Rich in Iron
 Ferrous Sulphate 200mg OD