18 year old student came with the chief complaints of
Fatigue since 1 month
SOB on exertion and physical activity since 1 month ( Grade -3 )
She was unable to do work on exertion. H/o chest pain which was relieved at rest. Palpitations positive.
Pedal edema Grade - 1 since 7 days , Facial puffiness since 7 days , Nausea & Vomitings since 3 days associated with food particles & not associated with blood.
No h/o Abdominal pain , pale colored stools, blood in stools
H/o Tingling since 20 days observed at rest , no tingling at regular work
Age of menarche - 12 years , 3/30 , Normal flow , No clots
Dietary history - H/o taking food twice a day mostly pickles , She consumes all vegetables ( not adequate ) , Less fruit intake
PAST HISTORY - No DM , HTN , CAD , ASTHMA , TB
FAMILY HISTORY - NAD
PERSONAL HISTORY -
Appetite - Normal
Diet - Mixed
Bowel & Bladder - Regular
Sleep - Adequate
Addictions - None
GENERAL EXAMINATION :
Pallor - Present , Edema of feet - Present
No Icterus , Cyanosis , Clubbing , Lymphadenopathy
VITALS :
PR - 120 bpm
BP - 80/50 mmhg
RR - 21 cpm
TEMP - AFEBRILE
SYSTEMIC EXAMINATION :
CVS - PSM heard
RS - BAE
P/A - Soft , Non tender
CNS - NAD
PROVISIONAL DIAGNOSIS :
Anemia under evaluation , Microcytic Hypochromic , IDA??
INVESTIGATIONS :
1. Inj. Iron Sucrose 1 Amp in 100 ml NS IV /OD
2. Inj. Methylcobalamine 1000 micrograms in 100 ml NS IV / OD
3. Tab. Orofer xt po/bd
4. Thrombophob oint thrice daily
Diet history : 847 kcal ( required is 2000 kcal )
Break fast - idly 3 + chutney 3 tbsp , milk one glass (448)
Lunch - rice 1katori , dal 4tbsp (189)
Dinner- rice 1 katori , curry 4tbsp (210)
Course in hospital :
18 yr old female came to old with severe anemia and high output cardiac failure. Patient dietary history suggestive of nutritional anemia. Patient was given 2 units of PRBC transfusions with one day gap on 15/06/2021 & 17/06/2021. After blood transfusion her shortness of breath subsided. She was given Iron& vit b12 supplements and asked to continue.
Advise at discharge :
1. Inj. Methylcobalamine 1000 micrograms IM/OD on 22/06/2021 , 29/06/2021 , 06/07/2022 , 13/07/2021 , 20/07/2021 , 20/08/2021 , 20/09/2021.
2. Tab Orofer xt po/bd
Follow up after 15 days
DSCHARGE SUMMARY :
Diagnosis :
NUTRITIONAL ANEMIA - DIMORPHIC
ANEMIC RETINOPATHY
Case History and Clinical Findings :
18 year old student came with the chief complaints ofFatigue since 1 monthSOB on exertion and
physical activity since 1 month ( Grade -3 )She was unable to do work on exertion. H/o chest pain
which was relieved at rest. Palpitations positive.Pedal edema Grade - 1 since 7 days , Facial
puffiness since 7 days , Nausea &Vomitings since 3 days associated with food particles ¬
associated with blood.No h/o Abdominal pain , pale colored stools, blood in stoolsH/o Tingling since
20 days observed at rest , no tingling at regular workAge of menarche - 12 years , 3/30 , Normal flow
, No clotsDietary history - H/o taking food twice a day mostly pickles , She consumes all vegetables ( not adequate ) , Less fruit intake.
Diet history : 847 kcal ( required is 2000 kcal ) Break fast - idly 3 +chutney 3 tbsp , milk one glass (448) Lunch - rice 1katori , dal 4tbsp (189) Dinner- rice 1 katori , curry4tbsp (210)
GENERAL EXAMINATION :Pallor - Present , Edema of feet - PresentNo Icterus ,
Cyanosis , Clubbing , Lymphadenopathy
VITALS :PR - 120 bpmBP - 80/50 mmhgRR - 21 cpmTEMP -AFEBRILE
SYSTEMIC EXAMINATION :CVS - PSM heard RS - BAE P/A - Soft , Non tender CNS -NAD
COURSE IN HOSPITAL :18 year old female came to opd with severe anemia and high output
cardiac failure. patient dietary history suggestive of nutritional anemia. patient was given 2 units of
PRBC transfusion with one day gap on 15/06/2021 &17/06/2021.After blood transfusionpatient
shortness of breath subsided. She was given iron &vit b 12 supplements and asked to continue the
same.
Investigations :
HEMOGRAM :
Hb - 2.1 gm/dl
Total count - 3300 cells / cumm
Neutrophils - 30
Lymphocytes - 64
Esinophils - 02
Monocytes - 04
Basophils - 00
PCV - 6.2 vol%
MCV - 117.0 fl
MCH - 40.4 pg
MCHC - 34.5 %
RDW-CV - 38.2 %
RDW-SD - 167.8 fl
RBC count - 0.53 millions/cumm
Platelet count - 1.0 lakhs/cumm
SMEAR :
RBC - Anisopoikilocytosis with microcytes , macrocytes , macroovalocytes , tear drop cells . pencil
forms seen
WBC - Decreased in count with relative lymphocytosis
PLATETS - Reduced on smear
HEMOPARASITES - none
IMPRESSION - Pancytopenia
RETIC COUNT - 0.3 %
BLOOD GROUPING &RH TYPING - O +VE
ESR - 90 mm/1st hour
HEMOGRAM :
Hb - 4.6 gm/dl
Total count - 3000 cells / cumm
Neutrophils - 35
Lymphocytes - 57
Esinophils - 02
Monocytes - 06
Basophils - 00
PCV - 13.1 vol%
MCV - 103.2 fl
MCH - 36.0 pg
MCHC - 34.9 %
RDW-CV - 23.6 %
RDW-SD - 92.8 fl
RBC count - 1.27 millions/cumm
Platelet count - 1.5 lakhs/cumm
SMEAR :
RBC - Anisopoikilocytosis with microcytes , macrocytes , macroovalocytes
WBC - Reduced on smear
PLATETS - Adequate in number and distribution
HEMOPARASITES - none
IMPRESSION - Dimorphic Anemia with Leukopenia
IRON PROFILE :
Iron - 205 micrograms/dl
TIBC - 308 micrograms/dl
Trasferrin Saturation - 66.6%
VITAMIN B12 - 452 pg/ml
ULTRASOUND - B/l mild pleural effusion
Treatment Given(Enter only Generic Name)
1. INJ. METHYLCOBALAMINE 1000 micrograms/IM/OD
2. TAB. OROFER-XT PO/BD
3. INJ. IRON SUCROSE 1 amp in 100ml NS /IV/OD
4. THROMBOPHOB OINT THRICE DAILY
Advice at Discharge
1. INJ.METHYLCOBALAMINE 1000 MICROGRAMS/IM/OD
ON 22/06/2021 , 29/06/2021 , 06/07/2021 , 13/07/2021 , 20/07/2021 , 20/08/2021 , 20/09/2021
2. TAB. OROFER-XT PO/BD
Follow Up :
REVIEW AFTER 15 DAYS
When to Obtain Urgent Care:
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed
and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been
explained to me in my own language
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