Diagnosis
IRON DEFICIENCY ANAEMIA
Case History and Clinical Findings
C/O GENERALIZED WEAKNESS SINCE 7 DAYS
C/O FEVER SINCE 7 DAYS
C/O HEAD ACHE SINCE 7 DAYS
C/O SWELLING OF FACE SINCE 1 DAY
PATIENT WAS APPRENTLY ASYMPTOMATIC 7 DAYS AGO THEN DEVELOPED FEVER,LOW
GRADE ASSOCIATED WITH CHILLS
HEAD ACHE IS BILATERAL(OCCIPUT REGION),PRICKING TYPE INSIDIOUS IN
ONSET,GRADUALLY PREGRESSIVE,NO AGGRAVATING OR RELEIVING FACTORS,THEN SHE
DEVELOPED SWELLING FOR FACE 1 DAY BACK SUDDEN IN ONSET
H/O DYSPNEA 5 DAYS AGO,GRADE III
H/O COUGH WITHOUT EXPECTORATION 1 WEEK BACK
H/O COLD 1 WEEK BACK
NO C/O VOMITINGS,NAUSEA,PHOTOPHOBIA,PHONOPHOBIA,HEAD ACHE
FEVER,COUGH,COLD PRESENT
NO H/O VOMITINGS,PEDAL EDEMA,INCREASE OR DECRTEASE IN URINATION ,PASSAGE OF
LOOSE STOOLS,CONSTIPATION
N/K/C/O HTN/DM/TB/ASTHMA/EPILEPSY
H/O ONE UNIT PRBC TRANSFUSION 15 YRS AGO
GENERAL EXAMINATION:
PATIENT IS CONSCIOUS,COHERENT AND CO OPERATIVE
PALLOR PRESENT
NO CYANOSIS,CLUBBING,LYMPHADENOPATHY,PEDAL EDEMA
TEMPERATURE 98.4 F
PULSE RATE 80 BPM
RR - 18 CPM
BP - 110/70 MM HG
SPO2 98% AT RA
CVS - S1,S2 HEARD,NO MURMURS
RS - BILATERAL AIR ENTRY PRESENT
PER ABDOMEN - SOFT,NON TENDER,NO ORGANOMEGALY
CNS - NO FOCAL NEUROLOGICAL DEFICIT
1 UNIT PRBC WAS TRANSFUSED ON 17/2/24,AND TRANFUSION WAS UNEVENTFUL
GYNAECOLOGICAL REFERRAL WAS DONE I/V/O AMENORRHEA SINCE 2 MONTHS FOR
WHICH THEY ADVISED TFT,USG-ABDOMEN AND PELVIS FOR ET
Investigation
Name Value Range
HBsAg-RAPID 17-02-2024 12:04:PM Negative
SEROLOGY NEGATIVE
BLOOD GROUP O POSITIVE
HEMOGRAM OM 17/2/24
HAEMOGLOBIN # 6.2 gm/dl 12.0 - 15.0
TOTAL COUNT 7,800 cells/cumm 4000 - 10000
NEUTROPHILS 61 % 40 - 80
LYMPHOCYTES 30 % 20 - 40
EOSINOPHILS 05 % 01 - 06
MONOCYTES 04 % 02 - 10
BASOPHILS 00 % 0 - 2
PCV # 22.5 vol % 36 - 46
M C V # 66.8 fl 83 - 101
M C H # 18.4 pg 27 - 32
M C H C # 27.6 % 31.5 - 34.5
RDW-SD 46.6 fl 39.0-46.0
RBC COUNT # 3.37 millions/cumm 3.8 - 4.8
PLATELET COUNT 3.36 lakhs/cu.mm 1.5-4.1
SMEAR
RBC Anisopoikilocytosis with normocytes, microcytes , macrocytes , macroovalocytes few tear drop
and pencil forms
WBC normal counts on smear Light Microscopy
PLATELETS Adequate in number and distribution
HEMOPARASITES No hemoparasites seen
IMPRESSION Dimoprphic Anemia
BLOOD UREA 17-02-2024 12:04:PM 16 mg/dl 42-12 mg/dl
SERUM CREATININE 17-02-2024 12:04:PM 0.8 mg/dl 1.1-0.6 mg/dl
SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 17-02-2024 12:04:PM
SODIUM 140 mEq/L 145-136 mEq/L
POTASSIUM 4.2 mEq/L 5.1-3.5 mEq/L
CHLORIDE 101 mEq/L 98-107 mEq/L
CALCIUM IONIZED 1.22 mmol/L mmol/L
COMPLETE URINE EXAMINATION (CUE) 17-02-2024 12:04:PM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN Nil
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 2-3
EPITHELIAL CELLS 1-2
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS DEPOSITS NIL
OTHERS Nil
PERIPHERAL SMEAR 17-02-2024 12:04:PM RBC : Anisopoikilocytosis with normocytes , microcytes
, macrocytes , macro ovalocytes few tear drop and pencil forms WBC : normal counts on smear
PLATELET : Adequate
BLOOD UREA 18-02-2024 04:10:AM 23 mg/dl 42-12 mg/dl
 |
SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 18-02-2024 04:10:AM
SODIUM 139 mEq/L 145-136 mEq/L
POTASSIUM 3.8 mEq/L 5.1-3.5 mEq/L
CHLORIDE 101 mEq/L 98-107 mEq/L
CALCIUM IONIZED 1.20 mmol/L mmol/L
COMPLETE BLOOD PICTURE (CBP) 18-02-2024 04:10:AM
HAEMOGLOBIN 8.8 gm/dl 15.0-12.0 gm/dl
TOTAL COUNT 14400 cells/cumm 10000-4000 cells/cumm
NEUTROPHILS 77 % 80-40 %
LYMPHOCYTES 20 % 40-20 %
EOSINOPHILS 01 % 6-1 %
MONOCYTES 02 % 10-2 %
BASOPHILS 00 % 2-0 %
PLATELET COUNT 4.8
SMEAR microcytic hypochromic anemia with leukocytosis
CBP ON 19/2/24
HAEMOGLOBIN # 8.6 gm/dl 12.0 - 15.0
TOTAL COUNT 8,700 cells/cumm 4000 - 10000
NEUTROPHILS 71 % 40 - 80
LYMPHOCYTES 21 % 20 - 40
EOSINOPHILS 04 % 1 - 6
MONOCYTES 04 % 2 - 10
BASOPHILS 00 % 0 - 2
PLATELET COUNT 4.65 lakhs/cu.mm 1.5-4.1
SMEAR Microcytic hypochromic anemia
SERUM ELECTROLYTES ON 19/2/24
SODIUM 140 mEq/L 136 - 145
POTASSIUM 4.0 mEq/L 3.5 - 5.1
CHLORIDE 103 mEq/L 98 - 107
CALCIUM IONIZED 1.27 mmol/L
Treatment Given(Enter only Generic Name)
TAB.MVT PO OD
INJ.IRON SUCROSE 1 AMP IN 100 NS IV
Advice at Discharge
IRON RICH DIET
TAB.OROFER XT PO ONCE A DAY AT 7 AM X 15 DAYS
TAB.NEUROKIND GOLDPO ONCE A DAY X 15 DAYS
DISCHARGE SUMMARY
Diagnosis
IRON DEFICIENCY ANAEMIA
Case History and Clinical Findings
C/O GENERALIZED WEAKNESS SINCE 7 DAYS
C/O FEVER SINCE 7 DAYS
C/O HEAD ACHE SINCE 7 DAYS
C/O SWELLING OF FACE SINCE 1 DAY
PATIENT WAS APPRENTLY ASYMPTOMATIC 7 DAYS AGO THEN DEVELOPED FEVER,LOW
GRADE ASSOCIATED WITH CHILLS
HEAD ACHE IS BILATERAL(OCCIPUT REGION),PRICKING TYPE INSIDIOUS IN
ONSET,GRADUALLY PREGRESSIVE,NO AGGRAVATING OR RELEIVING FACTORS,THEN SHE
DEVELOPED SWELLING FOR FACE 1 DAY BACK SUDDEN IN ONSET
H/O DYSPNEA 5 DAYS AGO,GRADE III
H/O COUGH WITHOUT EXPECTORATION 1 WEEK BACK
H/O COLD 1 WEEK BACK
NO C/O VOMITINGS,NAUSEA,PHOTOPHOBIA,PHONOPHOBIA,HEAD ACHE
FEVER,COUGH,COLD PRESENT
NO H/O VOMITINGS,PEDAL EDEMA,INCREASE OR DECRTEASE IN URINATION ,PASSAGE OF
LOOSE STOOLS,CONSTIPATION
N/K/C/O HTN/DM/TB/ASTHMA/EPILEPSY
H/O ONE UNIT PRBC TRANSFUSION 15 YRS AGO
GENERAL EXAMINATION:
PATIENT IS CONSCIOUS,COHERENT AND CO OPERATIVE
PALLOR PRESENT
NO CYANOSIS,CLUBBING,LYMPHADENOPATHY,PEDAL EDEMA
TEMPERATURE 98.4 F
PULSE RATE 80 BPM
RR - 18 CPM
BP - 110/70 MM HG
SPO2 98% AT RA
CVS - S1,S2 HEARD,NO MURMURS
RS - BILATERAL AIR ENTRY PRESENT
PER ABDOMEN - SOFT,NON TENDER,NO ORGANOMEGALY
CNS - NO FOCAL NEUROLOGICAL DEFICIT
1 UNIT PRBC WAS TRANSFUSED ON 17/2/24,AND TRANFUSION WAS UNEVENTFUL
GYNAECOLOGICAL REFERRAL WAS DONE I/V/O AMENORRHEA SINCE 2 MONTHS FOR
WHICH THEY ADVISED TFT,USG-ABDOMEN AND PELVIS FOR ET
Investigation
Name Value Range
HBsAg-RAPID 17-02-2024 12:04:PM Negative
SEROLOGY NEGATIVE
BLOOD GROUP O POSITIVE
HEMOGRAM OM 17/2/24
HAEMOGLOBIN # 6.2 gm/dl 12.0 - 15.0
TOTAL COUNT 7,800 cells/cumm 4000 - 10000
NEUTROPHILS 61 % 40 - 80
LYMPHOCYTES 30 % 20 - 40
EOSINOPHILS 05 % 01 - 06
MONOCYTES 04 % 02 - 10
BASOPHILS 00 % 0 - 2
PCV # 22.5 vol % 36 - 46
M C V # 66.8 fl 83 - 101
M C H # 18.4 pg 27 - 32
M C H C # 27.6 % 31.5 - 34.5
RDW-SD 46.6 fl 39.0-46.0
RBC COUNT # 3.37 millions/cumm 3.8 - 4.8
PLATELET COUNT 3.36 lakhs/cu.mm 1.5-4.1
SMEAR
RBC Anisopoikilocytosis with normocytes, microcytes , macrocytes , macroovalocytes few tear drop
and pencil forms
WBC normal counts on smear Light Microscopy
PLATELETS Adequate in number and distribution
HEMOPARASITES No hemoparasites seen
IMPRESSION Dimoprphic Anemia
BLOOD UREA 17-02-2024 12:04:PM 16 mg/dl 42-12 mg/dl
SERUM CREATININE 17-02-2024 12:04:PM 0.8 mg/dl 1.1-0.6 mg/dl
SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 17-02-2024 12:04:PM
SODIUM 140 mEq/L 145-136 mEq/L
POTASSIUM 4.2 mEq/L 5.1-3.5 mEq/L
CHLORIDE 101 mEq/L 98-107 mEq/L
CALCIUM IONIZED 1.22 mmol/L mmol/L
COMPLETE URINE EXAMINATION (CUE) 17-02-2024 12:04:PM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN Nil
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 2-3
EPITHELIAL CELLS 1-2
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS DEPOSITS NIL
OTHERS Nil
PERIPHERAL SMEAR 17-02-2024 12:04:PM RBC : Anisopoikilocytosis with normocytes , microcytes
, macrocytes , macro ovalocytes few tear drop and pencil forms WBC : normal counts on smear
PLATELET : Adequate
BLOOD UREA 18-02-2024 04:10:AM 23 mg/dl 42-12 mg/dl
SERUM CREATININE 18-02-2024 04:10:AM 0.8 mg/dl 1.1-0.6 mg/dl
SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 18-02-2024 04:10:AM
SODIUM 139 mEq/L 145-136 mEq/L
POTASSIUM 3.8 mEq/L 5.1-3.5 mEq/L
CHLORIDE 101 mEq/L 98-107 mEq/L
CALCIUM IONIZED 1.20 mmol/L mmol/L
COMPLETE BLOOD PICTURE (CBP) 18-02-2024 04:10:AM
HAEMOGLOBIN 8.8 gm/dl 15.0-12.0 gm/dl
TOTAL COUNT 14400 cells/cumm 10000-4000 cells/cumm
NEUTROPHILS 77 % 80-40 %
LYMPHOCYTES 20 % 40-20 %
EOSINOPHILS 01 % 6-1 %
MONOCYTES 02 % 10-2 %
BASOPHILS 00 % 2-0 %
PLATELET COUNT 4.8
SMEAR microcytic hypochromic anemia with leukocytosis
CBP ON 19/2/24
HAEMOGLOBIN # 8.6 gm/dl 12.0 - 15.0
TOTAL COUNT 8,700 cells/cumm 4000 - 10000
NEUTROPHILS 71 % 40 - 80
LYMPHOCYTES 21 % 20 - 40
EOSINOPHILS 04 % 1 - 6
MONOCYTES 04 % 2 - 10
BASOPHILS 00 % 0 - 2
PLATELET COUNT 4.65 lakhs/cu.mm 1.5-4.1
SMEAR Microcytic hypochromic anemia
SERUM ELECTROLYTES ON 19/2/24
SODIUM 140 mEq/L 136 - 145
POTASSIUM 4.0 mEq/L 3.5 - 5.1
CHLORIDE 103 mEq/L 98 - 107
CALCIUM IONIZED 1.27 mmol/L
Treatment Given(Enter only Generic Name)
TAB.MVT PO OD
INJ.IRON SUCROSE 1 AMP IN 100 NS IV
Advice at Discharge
IRON RICH DIET
TAB.OROFER XT PO ONCE A DAY AT 7 AM X 15 DAYS
TAB.NEUROKIND GOLDPO ONCE A DAY X 15 DAYS
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