CHIEF COMPLAIN Miss siti norzila, 20 year old malay girl, a known case of Thallasemia presented to HSB 9 days

ago (19/4) due to fever, cough, SOB, and yellowish discolouration of the sclera 2 days prior to admission.. Regarding the fever, it was sudden in onset, continuous in nature, low grade and assoc with chills but no rigor. She did not take any medication for the fever. It was more severe at night / day.? The fever also came along with dizziness, generalised body weakness and easily feeling fatigue. No muscle pain, no joint pain, no headache or abdominal pain, no hx of travelling or jungle trekking. She also had LOA but no LOW. Regarding the cough, it was productive with yellowish sputum, started together with the fever. It also came along with shortness of breath in which she claimed that, even with 2-3 steps, she already feel breathless. She cant even complete a sentence but with rest, the SOB subsided. She mentioned that, she had reduced in effort tolerance since childhood in which she cant run or join any physical activities at school due to her condition (since being dx with Th). No wheezing, no chest pain and no coughing out blood. However, she also complained of palpitations but no PND, no ortopnoea, no leg swelling. About the yellowish discolouration of the eyes, she noticed it since childhood but claimed that when she had fever, the colour become much more obvious. She claimed that there was no changes in urine or stool colour. There was also no abdominal pain, no itchiness, no pain during urination, no nausea or vomiting and no other [obstructructive or irritative] urinary sx.

SYSTEMIC REVIEW GENERAL- fever, LOA, fatigue and generalised body weakness, no LOW CNS-no headache, no LOC. No seizures CVS- palpitation, no chest pain, PND, orthopnoea, leg sweliing ENT- no ear or nasal discharge RESPI- cough+ yellowish sputum, SOB, No wheezing, no hemoptysis, no sore throat GIT- no abd pain, no nausea and vomiting, no constipation, no diarrhoea GU- no dysuria, no urgency, no frequency, nocturia, hesitancy, dribbling, incontinence, poor stream MSK- no athralgia or myalgia SKIN- no bleeding tendencies

PAST MEDICAL She was a known case of Thallasemia since infancy and been in and out of hospital for multiple times, usually for blood transfusion. Last admission was March 2011 in which she presented with same sx like current admission and had received 5 bags of pack cells. She was discharged after 1 week and had been well until this current admission. No other chronic illness.

DRUG HISTORY Had not been taking any medication for this current condition but claimed to be given tablets to increase the cell count after being discharged last year. But, she was not very compliance. Name of drug?freq? any follow up?

Allergy No allergy toward any drugs or foods. FAMILY HX She was the ?? out of 9 siblings. 4 other siblings also had Thallassmia and dx since child too. All of them required blood transfusion too but is their condition better than her. All other sibling and parents are well. But according to her, her grandfather on her maternal side also had Thallasemia.

SOCIAL HX She is single,unmarried, lady work as a promoter with income of RM1000. She lived in Kota Damansara with her friends in flat house. She is not smoking, drinking, elicits drugs and no sexual promiscuity. In summary, Miss NZ, 20 year old Malay girl with underlying thallasemia requiring blood transfusion presented to HSB with fever, cough, SOB and jaundice 2 days prior to admission.

PE Generally, patient was lying supine, not in acute distress. She looks thin and pale. Her vital signs was normal BP: PR-92bpm RR-20 Temp- 37 On examination of the hand, palm is warm and dry, pale, peripheral cyanosis, no clubbing, no koilonychias and no leuchonyhychia. CRT < 2sec. Conjunctiva is pale, sclera is jaundiced, [no corneal arcus, xanthelasma etc] Oral hygiene is good, tongue is not coated, no central cyanosis, frenulum is pale,buccal mucosa is moist, no ulcers . No lymphadenopathy, no neck swelling.

RESPI INSPECTION- normal chest shape, moves symmetrically with respiration, no visible pulses, no intercostals recession PALPATION- no tracheal deviation,normal chest expansion, apex beat at left 5th intercostals space MCL, normal character, norma tactile fremitus PERCUSSION-normal resonance all the way AUSCULTATION- normal vesicular breath sound with generalised crepitations all the way, normal vocal resonance

CVS INSPECTION- no abn of the precordium, no visible pulsesno scars PALPATION- apex beat at left 5th intercostals space MCL, normal character,no heaves or thrills PERCUSSION-normal cardiac dullness AUSCULTATION- first hearst sound heard, normal intensity, normal character, second heart sound heard, no S3 or S4, gallop rhythm, no murmur

ABDOMEN INSPECTION- abd is flat, not distended, moves with respiration, no dilated veins, no scars PALPATION- warm,soft and non-tender on superficial palpation, on deep palpation, no tenderness. Hepatomegaly 3 fb( 16 cm), splenomegaly (descend towards umbilicus-6cm), kidney not ballotable PERCUSSION- dullness over the liver region (RHC and RL), and dull over splenic area (LHC and inferriormedially towards umbilicus), abd resonance all the way, no ascites, no shifting dullness AUSCULTATION- normal bower sound heard, no renal bruit. In summary, on PE, patient is thin, jaundice and pale. Generalised crepitations on respiratory examination and hepato splenomegaly.