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 &ggeneralised 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 - absentclubbing:absentcyanosis:absentLymphadenopathy: absentEdema: absent
VITALS on admission :Temp:afebrileBP: 110/70 mmHgPR- 82 bpmRR- 17 breaths per
minSYSTEMIC 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.NFNDabdominal 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 <.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 weaknesson
further evaluation diagnosed asIRON 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
DISCHARGE SUMMARY
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 &ggeneralised 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 - absentclubbing:absentcyanosis:absentLymphadenopathy: absentEdema: absent
VITALS on admission :Temp:afebrileBP: 110/70 mmHgPR- 82 bpmRR- 17 breaths per
minSYSTEMIC 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.NFNDabdominal 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 <.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 weaknesson
further evaluation diagnosed asIRON 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
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