Diagnosis
IRON DEFICIENCY ANEMIA TO BLOOD LOSS (ANAL FISSURE)
Case History and Clinical Findings
C/O HEADCHE SINCE 1 WEEK
C/O VOMITINGS 2 DAYS BACK
C/O HEAVINESS OF CHEST SINCE 2 DAYS
PT WAS APPARENTLY ASYMPTOMATIC 1MONTH BACK THEN SHE HAD 2 EPISODES OF
VOMITING TREATED SYMPTOMATICALLY
A/W HEADACHE NON PROJECTILE NON BILIOUS FOOD PARTICLES CONTENT
MENSTRUAL HISTORY - 3 DAYS/30DAYS CLOTS - , PAIN -
H/O IRREGULAR MENSTRUATION CYCLES
MENARCHE AT 17Y
NO H/O CHEST PAIN, SHORTNESS OF BREATH ,PAIN ABDOMEN ,LOOSE STOOLS, NAUSEA+
,VOMITING -, FEVER -, WORM INFESTATION - ,PICA-
H/O BLEEDING PER RECTUM 1 EPISODE - TODAY [FEW RED DROPS IN STOOL]
-HEMOPTYSIS -, HEMETEMESIS - ,BLEEDING GUMS
HEADACHE - UNILATERAL THROBBING TYPE NON RADIATING - NO NAUSEA , VOMITING , -
PHOTOPHOBIA
HEAVINESS OF CHEST - NOT A/W FOOD INTAKE NOT A/W EXERTION
NUTRITIONAL HISTORY;
MORNING - TIFFIN[IDLY , DOSA , BONDA , POORI ]
AFTERNOON - SAMBAR /CURRY/CURD+RICE
NO SNACKS
NIGHT - CURRY/PICKLE/CURD - RICE
NO SIMILAR COMPLAINTS IN PAST
N/K/C/O DM , HTN , ASTHMA , CAD , TB , EPILEPSY , BLOOD TRANSFUSIONS-
PATIENT IS NOT WILLING FOR IRON SUCROSE SO 1 UNIT PRBC TRANSFUSION GIVEN.
Investigation
USG IMPRESSION -
MILDLY ALTERED ECHOTEXTURE OF LIVER
LOW LEVEL ECHOES IN URINARY BLADDER
Treatment Given(Enter only Generic Name)
1] INJ ZOFER 4 GM IV /SOS
2]INJ IRON SUCROSE 200 MG IN 100 ML NS OVER 2-3 HRS
3]IRON RICH DIET
4]TAB DOLO 650 MG PO/SOS
5] SYP CREMAFFIN 30 ML /PO/H/S
6]HIGH FIBRE DIET
7]ANOBLISS OINTMENT FOR LOCAL APPLICATION
8]SITZ BATH [BETADINE]
9]PLENTY OF ORAL FLUIDS
Advice at Discharge
TAB OROFER XT 100MG PO ONCE DAILY BEFORE FOOD X 1 MONTH
TAB VOMIKIND 4 MG PO SOS
TAB DOLO 650 MG PO/SOS
SYP CREMAFFIN 20 ML ONCE DAILY BED TIME
HIGH FIBRE DIET
ANOBLISS OINTMENT FOR LOCAL APPLICATION
SITZ BATH [BETADINE] /TID
PLENTY OF ORAL FLUIDS
DISCHARGE SUMMARY
Diagnosis
IRON DEFICIENCY ANEMIA TO BLOOD LOSS (ANAL FISSURE)
Case History and Clinical Findings
C/O HEADCHE SINCE 1 WEEK
C/O VOMITINGS 2 DAYS BACK
C/O HEAVINESS OF CHEST SINCE 2 DAYS
PT WAS APPARENTLY ASYMPTOMATIC 1MONTH BACK THEN SHE HAD 2 EPISODES OF
VOMITING TREATED SYMPTOMATICALLY
A/W HEADACHE NON PROJECTILE NON BILIOUS FOOD PARTICLES CONTENT
MENSTRUAL HISTORY - 3 DAYS/30DAYS CLOTS - , PAIN -
H/O IRREGULAR MENSTRUATION CYCLES
MENARCHE AT 17Y
NO H/O CHEST PAIN, SHORTNESS OF BREATH ,PAIN ABDOMEN ,LOOSE STOOLS, NAUSEA+
,VOMITING -, FEVER -, WORM INFESTATION - ,PICA-
H/O BLEEDING PER RECTUM 1 EPISODE - TODAY [FEW RED DROPS IN STOOL]
-HEMOPTYSIS -, HEMETEMESIS - ,BLEEDING GUMS
HEADACHE - UNILATERAL THROBBING TYPE NON RADIATING - NO NAUSEA , VOMITING , -
PHOTOPHOBIA
HEAVINESS OF CHEST - NOT A/W FOOD INTAKE NOT A/W EXERTION
NUTRITIONAL HISTORY;
MORNING - TIFFIN[IDLY , DOSA , BONDA , POORI ]
AFTERNOON - SAMBAR /CURRY/CURD+RICE
NO SNACKS
NIGHT - CURRY/PICKLE/CURD - RICE
NO SIMILAR COMPLAINTS IN PAST
N/K/C/O DM , HTN , ASTHMA , CAD , TB , EPILEPSY , BLOOD TRANSFUSIONS-
PATIENT IS NOT WILLING FOR IRON SUCROSE SO 1 UNIT PRBC TRANSFUSION GIVEN.
Investigation
USG IMPRESSION -
MILDLY ALTERED ECHOTEXTURE OF LIVER
LOW LEVEL ECHOES IN URINARY BLADDER
Treatment Given(Enter only Generic Name)
1] INJ ZOFER 4 GM IV /SOS
2]INJ IRON SUCROSE 200 MG IN 100 ML NS OVER 2-3 HRS
3]IRON RICH DIET
4]TAB DOLO 650 MG PO/SOS
5] SYP CREMAFFIN 30 ML /PO/H/S
6]HIGH FIBRE DIET
7]ANOBLISS OINTMENT FOR LOCAL APPLICATION
8]SITZ BATH [BETADINE]
9]PLENTY OF ORAL FLUIDS
Advice at Discharge
TAB OROFER XT 100MG PO ONCE DAILY BEFORE FOOD X 1 MONTH
TAB VOMIKIND 4 MG PO SOS
TAB DOLO 650 MG PO/SOS
SYP CREMAFFIN 20 ML ONCE DAILY BED TIME
HIGH FIBRE DIET
ANOBLISS OINTMENT FOR LOCAL APPLICATION
SITZ BATH [BETADINE] /TID
PLENTY OF ORAL FLUIDS
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