DIAGNOSIS
SEVERE IRON DEFICIENCY ANEMIA SECONDARY TO NUTRITIONAL DEFICIENCY
Case History and Clinical Findings
35 YEARS OLD FEMALE, CAME WITH CHIEF COMPLAINTS OF
1) SHORTNESS OF BREATH SINCE 3 MONTHS ,
2) FEVER SINCE 1 MONTH
3) GENERALISED WEAKNESS SINCE 1 MONTH
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 3 MONTHS BACK THEN SHE HAD SHORTNESS
OF BREATH WHICH RELIEVED ON TAKING REST ,NO ORTHOPNEA, NO PND.
-C/O GENERALISED WEAKNESS SINCE 1MONTH ,13 DAYS BACK SHE WENT TO THE
SURYAPET HOSPITAL ,THERE THEY DID HAEMOGRAM AND DIAGNOSED AS ANEMIA, AT
THAT TIME HER HB WAS 3 GM/DL.
-C/O FEVER SINCE 1 MONTH, INTERMITTENT IN NATURE.10 DAYS BACK SHE HAD HIGH
GRADE FEVER, ASSOCIATED WITH CHILLS AND RIGORS,RELIEVED ON TAKING
MEDICATION.
-C/O COUGH SINCE 2 DAYS ,WHICH IS PRODUCTIVE, YELLOWISH IN COLOUR AND NON FOUL SMELLING
-H/O HEAVY BLEEDING LAST MONTH (LASTED FOR 11 DAYS(1ST 6 DAYS HEAVY BLEEDING
THEN NEXT 2 DAYS BLEEDING, STOPPED THEN AGAIN 5 DAYS BLEEDING OCCURED)
-NO H/O BLOOD IN THE STOOLS, HEMATEMESIS , MALENA,HEMOPTYSIS.
PAST HISTORY:
NOT A K/C/O DIABETES,ASTHMA, CORONARY ARTERY DISEASES,EPILEPSY,THYROID
DISORDERS.
FAMILY HISTORY:
MOTHER PASSED AWAY DUE TO BRAIN TUMOUR.
ELDER SISTER PASSED AWAY DUE TO ?UTERINE CARCINOMA.
FATHER PASSED AWAY DUE TO EXCESSIVE ALCOHOL CONSUMPTION.
PERSONAL HISTORY:
DIET- MIXED
APPETITE - NORMAL
SLEEP -NORMAL
BOWEL AND BLADDER -REGULAR
ADDICTIONS- NONE
MENSTRUAL HISTORY-
-REGULAR CYCLE ,WITH NORMAL FLOW UNTIL LAST FEB.
-LAST MONTH (MARCH)HEAVY BLEEDING WITHOUT CLOTS ,LASTED FOR 11 DAYS (1ST 6
DAYS HEAVY BLEEDING THEN NEXT 2 DAYS BLEEDING IS STOPPED THEN AGAIN 5 DAYS
BLEEDING OCCURED)
GENERAL EXAMINATION:-
-PATIENT IS CONSCIOUS, COOPERATIVE, WITH SLURRED SPEECH
WELL ORIENTED TO TIME, PLACE AND PERSON
-THINLY BUILT AND MALNOURISHED.
PALLOR - PRESENT
ICTERUS - ABSENT
CYANOSIS - ABSENT
CLUBBING - ABSENT
KOILONYCHIA-PRESENT
LYMPHADENOPATHY - ABSENT
ODEMA_ ABSENT
VITALS:
TEMP:97.8°F
B.P:110/70 MMHG
P.R:82 BPM
R.R: 20 CPM
SYSTEMIC EXAMINATION:
ABDOMINAL EXAMINATION:
INSPECTION -
UMBILICUS - INVERTED
ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION. NO SCARS, SINUSES AND
ENGORGED VEINS , VISIBLE PULSATIONS.
HERNIAL ORIFICES- FREE.
PALPATION -
SOFT, NON-TENDER
NO PALPABLE SPLEEN AND LIVER
CARDIOVASCULAR SYSTEM:
INSPECTION :
SHAPE OF CHEST- ELLIPTICAL
NO ENGORGED VEINS, SCARS, VISIBLE PULSATIONS
JVP - NOT RAISED
PALPATION :
APEX BEAT CAN BE PALPABLE IN 5TH INTER COSTAL SPACE
NO THRILLS AND PARASTERNAL HEAVES CAN BE FELT
AUSCULTATION :
S1,S2 ARE HEARD
NO MURMURS
RESPIRATORY SYSTEM:
INSPECTION
SHAPE- ELLIPTICAL
B/L SYMMETRICAL ,
BOTH SIDES MOVING EQUALLY WITH RESPIRATION .
NO SCARS, SINUSES, ENGORGED VEINS, PULSATIONS
PALPATION:
TRACHEA - CENTRAL
EXPANSION OF CHEST IS SYMMETRICAL.
VOCAL FREMITUS - NORMAL
PERCUSSION: RESONANT BILATERALLY
AUSCULTATION:
BILATERAL AIR ENTRY PRESENT. NORMAL VESICULAR BREATH SOUNDS HEARD.
CENTRAL NERVOUS SYSTEM:
CONSCIOUS,COHERENT AND COOPERATIVE
SPEECH- NORMAL
NO SIGNS OF MENINGEAL IRRITATION.
CRANIAL NERVES- INTACT
SENSORY SYSTEM- NORMAL
MOTOR SYSTEM:
TONE- NORMAL
POWER- BILATERALLY 5/5
REFLEXES: RIGHT. LEFT.
BICEPS. ++. ++
TRICEPS. ++. ++
SUPINATOR ++. ++
KNEE. ++. ++
ANKLE ++. ++
COURSE IN THE HOSPITAL:-
35 YEAR OLD FEMALE CAME TO OPD WITH ABOVE MENTIONED COMPLAINTS. NECESSARY
INVESTIGATIONS WERE DONE AND DIAGNOSED WITH IRON DEFICENCY ANEMIA SECONDARY TO NUTRITIONAL DEFICIENCY.
AT THE TIME OF ADMISSION HEMOGLOBIN WAS 3.9, 2 PRBCS WERE TRANSFUSED AND
HEMOGLOBIN IMPROVED TO 7.
1 DOSE OF IRON SUCROSE100MG IN 100 ML NS IV WAS GIVEN ON 16/4/23 AND 18/4/23.
OBGYN REFERRAL WAS TAKEN I/V/O MENORRHAGIA AND ADVICE FOLLOWED
PATIENT IS HEMODYNAMICALLY STABLE AND PLANNED FOR DISCHARGE
REFERRAL:
OBGYN OPINION:
I/V/O MENORRHAGIA AND ADVICE IS FOLLOWED
Investigation
HEMOGRAM:
12/4/23
HB: 3.9
TLC: 9,300
PCV: 16.1
RBC:2.99 MILLIONS/CUMM
PLATELETS: 8 LAKHS/CUMM
13/4/23
HB: 5.5
TLC: 11,000
PCV: 20.5
RBC: 3.48 MILLIONS/CUMM
PLATELETS: 7.4 LAKHS/CUMM
15/4/23
HB: 5.7
TLC: 5000
PCV: 22.2
RBC: 3.72 MILLIONS/CUMM
PLATELETS: 2.19 LAKHS/CUMM
17/4/23
HB: 7
TLC: 10500
PCV: 26
RBC: 4.15 MILLIONS/CUMM
PLATELETS: 4.60 LAKHS/CUMM
BLOOD TRANSFUSION:
ON 13/4/23
1UNIT OF PRBC TRANSFUSION WAS DONE.
ON 15/4/23
1 UNIT OF PRBC TRANSFUSION WAS DONE.
USG: NO SONOLOGICAL ABNORMALITY DETECTED.
2D ECHO: MILD LVH IS PRESENT
EF: 66%
TRIVIAL MR+/TR+/AR+
NO RWMA, NO AS/MS
GOOD LV SYTOLIC FUNCTION
NO DIASTOLIC DYSFUNCTION, NO PAH
ECG: NORMAL SINUS RHYTHM
USG:
Treatment Given(Enter only Generic Name)
INJ. IRON SUCROSE 100MG IN 100 ML NS IV/WEEKLY THRICE -- >DOSE GIVEN
INJ. NEOMOL 1 GM IV/SOS IF TEMP >101F
TAB. OROFER-XT PO/BD --> 5 DAYS
TAB. DOLO 650 MG PO/SOS
Advice at Discharge
IRON RICH DIET
TAB. OROFER-XT PO/BD --> 1 MONTH
TAB.LIMCEE 500 MGPO/OD --> 1 MONTH
TAB. DOLO 650 MG PO/SOS
OINT. THROMBOPHOBE L/A B/D--> 3 DAYS
DISCHARGE SUMMARY
DIAGNOSIS
SEVERE IRON DEFICIENCY ANEMIA SECONDARY TO NUTRITIONAL DEFICIENCY
Case History and Clinical Findings
35 YEARS OLD FEMALE, CAME WITH CHIEF COMPLAINTS OF
1) SHORTNESS OF BREATH SINCE 3 MONTHS ,
2) FEVER SINCE 1 MONTH
3) GENERALISED WEAKNESS SINCE 1 MONTH
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 3 MONTHS BACK THEN SHE HAD SHORTNESS
OF BREATH WHICH RELIEVED ON TAKING REST ,NO ORTHOPNEA, NO PND.
-C/O GENERALISED WEAKNESS SINCE 1MONTH ,13 DAYS BACK SHE WENT TO THE
SURYAPET HOSPITAL ,THERE THEY DID HAEMOGRAM AND DIAGNOSED AS ANEMIA, AT
THAT TIME HER HB WAS 3 GM/DL.
-C/O FEVER SINCE 1 MONTH, INTERMITTENT IN NATURE.10 DAYS BACK SHE HAD HIGH
GRADE FEVER, ASSOCIATED WITH CHILLS AND RIGORS,RELIEVED ON TAKING
MEDICATION.
-C/O COUGH SINCE 2 DAYS ,WHICH IS PRODUCTIVE, YELLOWISH IN COLOUR AND NON FOUL SMELLING
-H/O HEAVY BLEEDING LAST MONTH (LASTED FOR 11 DAYS(1ST 6 DAYS HEAVY BLEEDING
THEN NEXT 2 DAYS BLEEDING, STOPPED THEN AGAIN 5 DAYS BLEEDING OCCURED)
NO H/O BLOOD IN THE STOOLS, HEMATEMESIS , MALENA,HEMOPTYSIS.
PAST HISTORY:
NOT A K/C/O DIABETES,ASTHMA, CORONARY ARTERY DISEASES,EPILEPSY,THYROID
DISORDERS.
FAMILY HISTORY:
MOTHER PASSED AWAY DUE TO BRAIN TUMOUR.
ELDER SISTER PASSED AWAY DUE TO ?UTERINE CARCINOMA.
FATHER PASSED AWAY DUE TO EXCESSIVE ALCOHOL CONSUMPTION.
PERSONAL HISTORY:
DIET- MIXED
APPETITE - NORMAL
SLEEP -NORMAL
BOWEL AND BLADDER -REGULAR
ADDICTIONS- NONE
MENSTRUAL HISTORY-
-REGULAR CYCLE ,WITH NORMAL FLOW UNTIL LAST FEB.
-LAST MONTH (MARCH)HEAVY BLEEDING WITHOUT CLOTS ,LASTED FOR 11 DAYS (1ST 6
DAYS HEAVY BLEEDING THEN NEXT 2 DAYS BLEEDING IS STOPPED THEN AGAIN 5 DAYS
BLEEDING OCCURED)
GENERAL EXAMINATION:-
-PATIENT IS CONSCIOUS, COOPERATIVE, WITH SLURRED SPEECH
WELL ORIENTED TO TIME, PLACE AND PERSON
-THINLY BUILT AND MALNOURISHED.
PALLOR - PRESENT
ICTERUS - ABSENT
CYANOSIS - ABSENT
CLUBBING - ABSENT
KOILONYCHIA-PRESENT
LYMPHADENOPATHY - ABSENT
ODEMA_ ABSENT
VITALS:
TEMP:97.8°F
B.P:110/70 MMHG
P.R:82 BPM
R.R: 20 CPM
SYSTEMIC EXAMINATION:
ABDOMINAL EXAMINATION:
INSPECTION -
UMBILICUS - INVERTED
ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION. NO SCARS, SINUSES AND
ENGORGED VEINS , VISIBLE PULSATIONS.
HERNIAL ORIFICES- FREE.
PALPATION -
SOFT, NON-TENDER
NO PALPABLE SPLEEN AND LIVER
CARDIOVASCULAR SYSTEM:
INSPECTION :
SHAPE OF CHEST- ELLIPTICAL
NO ENGORGED VEINS, SCARS, VISIBLE PULSATIONS
JVP - NOT RAISED
PALPATION :
APEX BEAT CAN BE PALPABLE IN 5TH INTER COSTAL SPACE
NO THRILLS AND PARASTERNAL HEAVES CAN BE FELT
AUSCULTATION :
S1,S2 ARE HEARD
NO MURMURS
RESPIRATORY SYSTEM:
INSPECTION
SHAPE- ELLIPTICAL
B/L SYMMETRICAL ,
BOTH SIDES MOVING EQUALLY WITH RESPIRATION .
NO SCARS, SINUSES, ENGORGED VEINS, PULSATIONS
PALPATION:
TRACHEA - CENTRAL
EXPANSION OF CHEST IS SYMMETRICAL.
VOCAL FREMITUS - NORMAL
PERCUSSION: RESONANT BILATERALLY
AUSCULTATION:
BILATERAL AIR ENTRY PRESENT. NORMAL VESICULAR BREATH SOUNDS HEARD.
CENTRAL NERVOUS SYSTEM:
CONSCIOUS,COHERENT AND COOPERATIVE
SPEECH- NORMAL
NO SIGNS OF MENINGEAL IRRITATION.
CRANIAL NERVES- INTACT
SENSORY SYSTEM- NORMAL
MOTOR SYSTEM:
TONE- NORMAL
POWER- BILATERALLY 5/5
REFLEXES: RIGHT. LEFT.
BICEPS. ++. ++
TRICEPS. ++. ++
SUPINATOR ++. ++
KNEE. ++. ++
ANKLE ++. ++
COURSE IN THE HOSPITAL:-
35 YEAR OLD FEMALE CAME TO OPD WITH ABOVE MENTIONED COMPLAINTS. NECESSARY
INVESTIGATIONS WERE DONE AND DIAGNOSED WITH IRON DEFICENCY ANEMIA SECONDARY TO NUTRITIONAL DEFICIENCY.
AT THE TIME OF ADMISSION HEMOGLOBIN WAS 3.9, 2 PRBCS WERE TRANSFUSED AND
HEMOGLOBIN IMPROVED TO 7.
1 DOSE OF IRON SUCROSE100MG IN 100 ML NS IV WAS GIVEN ON 16/4/23 AND 18/4/23.
OBGYN REFERRAL WAS TAKEN I/V/O MENORRHAGIA AND ADVICE FOLLOWED
PATIENT IS HEMODYNAMICALLY STABLE AND PLANNED FOR DISCHARGE
REFERRAL:
OBGYN OPINION:
I/V/O MENORRHAGIA AND ADVICE IS FOLLOWED
Investigation
HEMOGRAM:
12/4/23
HB: 3.9
TLC: 9,300
PCV: 16.1
RBC:2.99 MILLIONS/CUMM
PLATELETS: 8 LAKHS/CUMM
13/4/23
HB: 5.5
TLC: 11,000
PCV: 20.5
RBC: 3.48 MILLIONS/CUMM
PLATELETS: 7.4 LAKHS/CUMM
15/4/23
HB: 5.7
TLC: 5000
PCV: 22.2
RBC: 3.72 MILLIONS/CUMM
PLATELETS: 2.19 LAKHS/CUMM
17/4/23
HB: 7
TLC: 10500
PCV: 26
RBC: 4.15 MILLIONS/CUMM
PLATELETS: 4.60 LAKHS/CUMM
BLOOD TRANSFUSION:
ON 13/4/23
1UNIT OF PRBC TRANSFUSION WAS DONE.
ON 15/4/23
1 UNIT OF PRBC TRANSFUSION WAS DONE.
USG: NO SONOLOGICAL ABNORMALITY DETECTED.
2D ECHO: MILD LVH IS PRESENT
EF: 66%
TRIVIAL MR+/TR+/AR+
NO RWMA, NO AS/MS
GOOD LV SYTOLIC FUNCTION
NO DIASTOLIC DYSFUNCTION, NO PAH
ECG: NORMAL SINUS RHYTHM
USG:
Treatment Given(Enter only Generic Name)
INJ. IRON SUCROSE 100MG IN 100 ML NS IV/WEEKLY THRICE -- >DOSE GIVEN
INJ. NEOMOL 1 GM IV/SOS IF TEMP >101F
TAB. OROFER-XT PO/BD --> 5 DAYS
TAB. DOLO 650 MG PO/SOS
Advice at Discharge
IRON RICH DIET
TAB. OROFER-XT PO/BD --> 1 MONTH
TAB.LIMCEE 500 MGPO/OD --> 1 MONTH
TAB. DOLO 650 MG PO/SOS
OINT. THROMBOPHOBE L/A B/D--> 3 DAYS
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