IRON DEFICIENCY ANEMIA SECONDARY TO ? NUTRITIONAL CAUSE WITH LEFT EAR OTOMYCOSIS

 Diagnosis

IRON DEFICIENCY ANEMIA SECONDARY TO ? NUTRITIONAL CAUSE WITH LEFT EAR OTOMYCOSIS

Case History and Clinical Findings

CHIEF COMPLAINTS :

SOB ON EXERTION SINCE 1 MONTH

GENERALIZED WEAKNESS SINCE 1MONTH

LT.EAR PAIN SINCE 1 MONTH

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 1 month back and then she noticed SOB on exertion(while doing work) since 1 month and stopped her work 20 days back & aggeneralised weakness since 1 month.

No h/o fever,cough ,PND, orthopnea

SEQUENCE OF EVENTS:

5 years back(in 2017) patient had chest pain and SOB on exertion and was diagnosed with anemia and had PRBC transfusion.she used to take oral iron(orofer) for 1 yr after that.

In 2021,August she came with complaints of headache(right occipital region),vomitings and giddiness and got treated for the same.she had one more PRBC transfusion

Now,she complaints of left ear pain and left ear discharge since 1 month and diagnosed with otomycosis,is on medications

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.Well oriented to time place and person.patient is lean and malnourished.

pallor - presenticterus -absent , clubbing:absent cyanosis:absent ,Lymphadenopathy: absent Edema: absent

VITALS on admission :Temp:afebrileBP: 110/70 mmHgPR- 82 bpmRR- 17 breaths per min

SYSTEMIC EXAMINATION:

Cardiovascular system- s1 and S2 are heard no murmurs

Respiratory system:trachea central, all quadrants of chest moves equally with respiration.Breath sounds- bilateral normalVesicular breath sounds are heard.

Central nervous system- Patient was conscious, coherent and cooperativeSpeech was normal.NFND 

abdominal examination :Inspection:flat abdomen, umbilicus centre and inverted.Palpation:soft,non-tender,enlarged spleen,percussion:no shifting dullness, no fluid thrills.auscultation:normal bowel sounds are heard.

BRIEF COURSE IN THE HOSPITAL : a 42 years old female came with c/o SOB ON EXERTION SINCE 1 MONTH ;GENERALIZED WEAKNESS SINCE 1MONTH &LT.EAR PAIN SINCE 1 MONTH. ENT opinion was taken on 25/06/22 and diagnosed as LEFT EAR OTOMYCOSIS and was on follow up with ENT department.But admitted under general medicine in v/o sob on exertion and generalized weakness on further evaluation diagnosed as IRON DEFICIENCY ANEMIA SECONDARY TO ? NUTRITIONAL CAUSE WITH LEFT EAR OTOMYCOSIS managed accordingly 2 units of PRBC TRANSFUSION was done on 7/07/2022 &9/07/2022. Mild transfusion reactions are noted after 1st PRBC transfusion which was managed conservatively. ENT review was taken on 12/07/2022 in v/o lt.ear pain and discharge. they did AURAL TOILETING and advised candid ear drops and to keep ear dry. pt.vitals are stable at the time of discharge.

Investigation

HEMOGRAM : 6/07/22 8/07/22 9/07/22 10/07/22 12/07/22

HB - 4.7 6.7 5.3 7.8 7.9

TLC - 6500 18500 3000 17500 10200

PLATELETS - 2.5 1.5 1.5 1.6 2.39

MCV - 71.9 69.3 65.1 77.2 80.6

MCH - 18.6 24 19.8 22.3 22.8

MCHC - 25.8 30.3 30.5 28.8 28.3

RBC - 2.53 3.2 2.6 3.37 3.46

BGT - O POSITIVE

S.IRON - 35

S.LDH - 225

SEROLOGY - NEGETIVE

T3 - 0.96

T4 - 13.94

TSH - 5.18

CRP - NEGETIVE

ECG - NO SIGNIFICANT CHANGES NOTED

CXR PA VIEW - NO SIGNIFICANT CHANGES NOTED

USG ABDOMEN - SHOWED MILD SPLEENOMEGALY

2D ECHO -

NO MR/AR/TR

NO RWMA; SCLEROTIC AV &NO MS/AS

GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION PRESENT

Treatment Given(Enter only Generic Name)

INJ NERVIGEN 1 AMP IN 100ML NS IV OD FOR 4 DAYS

INJ IRON SUCROSE 200MG IN 100ML IV OD FOR 3 DAYS

2 UNITS OF PRBC TRANSFUSION DONE ON 7/07/22 &9/07/2022

TAB.CIPROFLOXACIN 500MG FOR 5 DAYS

TAB.PAN 40MG PO OD BBF FOR 5 DAYS

TAB.LEVOCET 5MG PO HS

CANDID EAR DROPS 3 DROPS TID

Advice at Discharge

IRON RICH DIET

TAB. OROFER XT FOR 7 DAYS

SYP.CITRALKA 10ML IN 1 GLASS OF WATER PO TID FOR 5 DAYS

CANDID EAR DROPS 3 DROPS TID

KEEP THE EARS DRY

AVOID EAR MANIPULATION.

Follow up:No limitation in physical activity