Case : 85 year male complaints of chest pain

 Note: This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.




Sri Charan D (28) 








CASE REPORT : 




A 42 year old female patient working in a hotel , resident of Chityala, Nalgonda came to casuality with complaints of ear pain (left )for 15 days . 




HISTORY OF PRESENT ILLNESSES:

The patient was apparently asymptomatic 15 days ago , the patient developed c/o pain in the ears on 6th July .She is also suffering from Shortness of breath on climbing stairs and was having generalised weakness . 


The patient previously visited a local physician with left ear pain and fluid discharge from ear and decreased hearing .  He was prescibed with antiallergics on 28 June 2022 .


No c/o fever , cold and cough .



PAST HISTORY : 

Patient had  blood transfusion 5 years back .


Used oral Iron for 1 year and stopped 5 years ago .


Had chest pain 5 years ago .


No past HTN , DM , tuberculosis, asthma .






 FAMILY HISTORY:

Patient was not having similiar complaints in family .




PERSONAL HISTORY :

No decrease in appetite . 


Diet : mixed - Vegetarian 


She has regular dairy products and eats leafy vegetables twice a weak .


Her bowel and bladder movements are regular 


Her menses are regular and other bleeding manifestations .




Drug History : 







General Examination: 

Pallor :




No icterus / cyanosis / clubbing / lymphadenopathy/edema .


Patient is conscious, coherent and cooperative.




Clinical Images :




Lab Findings : 


















Probable Diagnosis :  


Iron deficiency Anaemia

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