Case : 42 year old female with c/o ear 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.

Dhanush Chandra J (50)

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