35 Yr old female with IRON DEFICIENCY ANEMIA

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

Case History and Clinical Findings 

CHIEF COMPLAINTS:

 A 35 YEAR OLD FEMALE CAME WITH THE-COMPLAINTS OF NECK PAIN AND HEAD ACHE SINCE 3 DAYS-COMPLAINTS OF GENRALISED WEAKNESS, GIDDINESS SINCE 3 DAYS-COMPLAINTS OF SHORTNESS OF BREATH ON AND OFF SINCE 3 DAYS 

HISTORY OF PRESENT ILLNESS::-PATIENT IS FINE SINCE 10 YEARS 

NOW SHE IS COMPLAINING OF NECK PAIN ,HEADACHE SINCE 3 DAYS AND ASSOCIATED WITH GENERALISED WEAKNESS ,GIDDINESS SINCE 3 DAYS PATIENT IS FEELING BREATHLESS- HAVING BREATHLESS EPISODES AND IS THEN WAITING UP FROM SLEEP, SUBSIDES IN 3 TO 5 MINUTES, SOB ON WALKING GRADE 2 ON AND OFF SINCE 3 DAYS, OUTSIDE HB 5.0GM/DL WAS REFERRED TO OUR HOSPITAL . NO COMPLAINTS OF ANY BLEEDING MANIFESTATIONS. NOW NO COMPLAINTS OF FEVER MENORRHAGIA, TINGLING OF LIMBS ,VOMITINGS LOOSE STOOLS. NON DM,HTN,THYROID DISORDE

.

 PAST HISTORY:17 YEARS AGO HISTORY OF MENORRHAGIA FOR 1 MONTH - HB-3MG/DL, 5. PRBC TRANSFERRED. 

15 YEARS AGO BIRTH OF MALE CHILD, NO COMPLICATIONS 13 YEARS AGO ?SEPTIC ABORTION, 2.PRBC TRANSFERRED I/V/O ANEMIA 10 YEARS AGO DURING PREGNANCY WAS TRANSFUSED WITH IRON INJECTIONS -BIRTH OF FEMALE CHILD (AFTER 4 YEARS CHILD DIED WITH FEBRILE SEIZURES) 

DIET-LEAFY VEGETABLES RARELY ONCE IN A MONTH OR 2 MONTHS ,NON VEG RAREY CHICKEN ,FISH .EATS MUTTON ONCE A WEEK OR ONCE TWO WEEKS, EATS VEGETABLES DAILY 

GENERAL EXAMINATION: 

TEMPERATURE 98.6 F

 PULSE-63BPM

RR:18CPM

 BP-120/70MM HG 

SPO2-98%

 @RA NO PIGMENTED KNUCKLES 

SYSTEMATIC EXAMINATION: 

PER ABDOMEN: SOFT, NON TENDER NO GUARDING, NO RIGIDITY BOWEL SOUNDS PRESENT 

CARDIOVASCULAR SYSTEM: S1,S2 HEARD, NO MURMURS 

RESPIRATORY SYSTEM: BAE PRESENT,NVBS 

INVESTIGATIONS::-

 SERUM FERRITIN 1.4

 CBP 17/5/22 HB: 5.0 GM/DL

 19/5/22 HB: 7.5 GM/DL

 

DIAGNOSIS::- IRON DEFICIENCY ANEMIA 

Treatment Given

(Enter only Generic Name) 

COURSE IN HOSPITAL:

 PT CAME WITH 3 DAYS H/O GIDDINESS , SOB ON EXERTION , GENERALISED WEAKNESS, H/O RECURRENT IRON DEFICIENCY ANEMIA IN PAST , 

ON EVALUATION WAS FOUND TO BE HAVING HB OF 5GM/DL, 

NORMAL TLC AND PLATELETS , 

SMEAR SHOWING MICROCYTIC , HYPOCHROMIC PICTURE WITH ANISOPOIKILOCYTOSIS ,

 LOW MCV , LOW MCH. 

DIETERY HISTORY REVEALED DEFICIENCY IN TAKING IRON RICH FOODS.

 SERUM FERRITIN WAS 1.4. PATIENT WAS TRANSFUSED WITH 1 UNIT PRBC ( POST TRANSFUSION HB: 7GM/DL) AND

 INJ. IRON SUCROSE 100 MG IN 100 ML NS ONE DOSE. 

TOTAL IRON DEFICIT IS 1400MG

 SO THE PATIENT HAS BEEN ADVICED FOR IRON SUCROSE INJECTIONS TO TAKE ON ALTERNATE DAYS AND

 IS BEING DISCHARGED IN HEMODYNAMICALLY STABLE STATUS

 1. TAB. OROFER PO OD

 2. 1 UNIT PRBC TRANSFUSION DONE

 Advice at Discharge:- 

 1. TAB. NEUROBION FORTE PO OD

 2. TAB. OROFER XT PO OD 

3. ALTERNATE DAY INJECTIONS OF INJ. IRON SUCROSE 200 MG + 100 ML NS OVER 1 HOUR * 5 DOSES

On follow up: No limitation in physical activity