A 37 yr Old female with Iron Deficiency Anemia

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 

A 37 Yr old FEMALE PATIENT CAME TO CASUALTY WITH CHIEF COMPLAINTS OF-DIZZINEES AND GENERALISED WEAKNESS SINCE 1 MONTH- DYSPNEA ON EXERTION AND ON CLIMBING STAIRS SINCE 1 MONTH. 

History of present Illness:-

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 YEARS BACK,THEN SHE DEVELOPED FEVER, SOB,FACIAL PUFFINESS AND PEDAL EDEMA, BODY PAINS FOR WHICHSHE WAS INVESTIGATED AT PRIVATE HOPITAL &DIAGNOSED WITH HB =4 G/DL AND TRANSFUSED BLOOD.C/O DIZZINEES AND GENERALISED WEAKNESS SINCE 1MONTH ASSOCIATED WITH DYSPNEA ONEXERTION AND ON CLIMBING STAIRS .NO H/O FEVER, MALENA,HEMOPTYSIS HEMATURIA NOT ASSOCIATED WITH MENSTRUAL IRREGULARITIES.NO H/O FEVER,MALENA,HEMOPTYSIS,HEMATURIA AND NOT ASSOCIATED WITH MENSTRUAL IRREGULARITIES.NO H/0 JAUNDICE PAST

PAST HISTORY ::-N/K/C/O HTN,DM,TB,BA,CVDH/O BLOOD TRANSFUSION AND POST TRANSFUSION WAS UNEVENFUL 

 PAST HISTORY ::- LOSS OF APPETITEBOWEL AND BLADDER MOVEMENTS REGULAR 

WEIGHT-38KG HEIGHT-152CM BMI-18DIET- EATS VEGETABLES DAILY,NON VEG CHICKEN, MUTTON ONCE IN A WEEK,LEAFY VEGETABLES ONCE IN A WEEk

  MENSTRUAL HISTORY::-AGE OF MENARCHE -14 YEAR,2/28AGE AT MARRIAGE-22 

VITALS BP-90/70MMHGPR-99BPMRR-32CPMSPO2 AT ROOM AIR -98GRBS-109MG/DL

PALLOR - PRESENT 

NO  ICTERUS/CLUBBING/EDEMA/LYMPHADENOPATHY

CVS-S1S2 HEARD

RS-BAE PRESENT

P/A- SOFT ,NON TENDERCNS-NAD.

 Investigations::-

USG  Abdomen::- NO SONOLOGICAL ABNORMALITY

DIAGNOSIS ::- IRON DEFICIENCY ANEMIA

 Treatment ::-Given(Enter only Generic Name) COURSE IN HOSPITALPATIENT WAS ADMITTED WITH H/O GENERALISED WEAKNESS AND SOB ON EXERTION,ON EVALUATION WAS FOUND TO HAVE IRON DEFICIENCY ANEMIA(HB:4.8).

IV IRON WAS GIVEN -IRON SUCROSE 500MG OVER 5-6DAYS 

.NOW IS BEING DISCHARGED IN HEMODYNAMICALLY STABLE STATUS WITH THE FOLLOWING ADVICE


DIAGNOSIS ::- IRON DEFICIENCY ANEMIA

 TREATMENT GIVEN 1.IRON SUCROSE 200MG+100ML NS 2.TAB OROFER XT PO OD 3.TAB NEUROBION FORTE OD Advice at Discharge 1.IRON RICH DIET 2.TAB OROFER XT PO OD x 1MONTH 3.TAB NEUROBION FORTE OD X 15DAYS

On follow up:No limitation in physical activity

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