SEVERE IRON DEFICIENCY ANEMIA SECONDARY TO NUTRITIONAL DEFICIENCY

DIAGNOSIS

SEVERE IRON DEFICIENCY ANEMIA SECONDARY TO NUTRITIONAL DEFICIENCY

Case History :

35 YEARS OLD FEMALE, CAME WITH CHIEF COMPLAINTS OF

1) SHORTNESS OF BREATH SINCE 3 MONTHS ,

2) FEVER SINCE 1 MONTH

3) GENERALISED WEAKNESS SINCE 1 MONTH

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 MONTHS BACK THEN SHE HAD SHORTNESS

OF BREATH WHICH RELIEVED ON TAKING REST ,NO ORTHOPNEA, NO PND.

-C/O GENERALISED WEAKNESS SINCE 1MONTH ,13 DAYS BACK SHE WENT TO THE

SURYAPET HOSPITAL ,THERE THEY DID HAEMOGRAM AND DIAGNOSED AS ANEMIA, AT

THAT TIME HER HB WAS 3 GM/DL.

-C/O FEVER SINCE 1 MONTH, INTERMITTENT IN NATURE.10 DAYS BACK SHE HAD HIGH

GRADE FEVER, ASSOCIATED WITH CHILLS AND RIGORS,RELIEVED ON TAKING MEDICATION.

-C/O COUGH SINCE 2 DAYS ,WHICH IS PRODUCTIVE, YELLOWISH IN COLOUR AND NON FOUL SMELLING

-H/O HEAVY BLEEDING LAST MONTH (LASTED FOR 11 DAYS(1ST 6 DAYS HEAVY BLEEDING

THEN NEXT 2 DAYS BLEEDING, STOPPED THEN AGAIN 5 DAYS BLEEDING OCCURED)

-NO H/O BLOOD IN THE STOOLS, HEMATEMESIS , MALENA,HEMOPTYSIS.

PAST HISTORY:

NOT A K/C/O DIABETES,ASTHMA, CORONARY ARTERY DISEASES,EPILEPSY,THYROID DISORDERS.

FAMILY HISTORY:

MOTHER PASSED AWAY DUE TO BRAIN TUMOUR.

ELDER SISTER PASSED AWAY DUE TO ?UTERINE CARCINOMA.

FATHER PASSED AWAY DUE TO EXCESSIVE ALCOHOL CONSUMPTION.

PERSONAL HISTORY:

DIET- MIXED

APPETITE - NORMAL

SLEEP -NORMAL

BOWEL AND BLADDER -REGULAR

ADDICTIONS- NONE

MENSTRUAL HISTORY-

-REGULAR CYCLE ,WITH NORMAL FLOW UNTIL LAST FEB.

-LAST MONTH (MARCH)HEAVY BLEEDING WITHOUT CLOTS ,LASTED FOR 11 DAYS (1ST 6

DAYS HEAVY BLEEDING THEN NEXT 2 DAYS BLEEDING IS STOPPED THEN AGAIN 5 DAYS BLEEDING OCCURED)

GENERAL EXAMINATION:-

-PATIENT IS CONSCIOUS, COOPERATIVE, WITH SLURRED SPEECH

WELL ORIENTED TO TIME, PLACE AND PERSON

-THINLY BUILT AND MALNOURISHED.

PALLOR - PRESENT

ICTERUS - ABSENT

CYANOSIS - ABSENT

CLUBBING - ABSENT

KOILONYCHIA-PRESENT

LYMPHADENOPATHY - ABSENT

ODEMA_ ABSENT

VITALS:

TEMP:97.8°F

B.P:110/70 MMHG

P.R:82 BPM

R.R: 20 CPM

SYSTEMIC EXAMINATION:

ABDOMINAL EXAMINATION:

INSPECTION -

UMBILICUS - INVERTED

ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION. NO SCARS, SINUSES AND

ENGORGED VEINS , VISIBLE PULSATIONS.

HERNIAL ORIFICES- FREE.

PALPATION -

SOFT, NON-TENDER

NO PALPABLE SPLEEN AND LIVER

CARDIOVASCULAR SYSTEM:

INSPECTION :

SHAPE OF CHEST- ELLIPTICAL

NO ENGORGED VEINS, SCARS, VISIBLE PULSATIONS

JVP - NOT RAISED

PALPATION :

APEX BEAT CAN BE PALPABLE IN 5TH INTER COSTAL SPACE

NO THRILLS AND PARASTERNAL HEAVES CAN BE FELT

AUSCULTATION :

S1,S2 ARE HEARD

NO MURMURS

RESPIRATORY SYSTEM:

INSPECTION

SHAPE- ELLIPTICAL

B/L SYMMETRICAL ,

BOTH SIDES MOVING EQUALLY WITH RESPIRATION .

NO SCARS, SINUSES, ENGORGED VEINS, PULSATIONS

PALPATION:

TRACHEA - CENTRAL

EXPANSION OF CHEST IS SYMMETRICAL.

VOCAL FREMITUS - NORMAL

PERCUSSION: RESONANT BILATERALLY

AUSCULTATION:

BILATERAL AIR ENTRY PRESENT. NORMAL VESICULAR BREATH SOUNDS HEARD.

CENTRAL NERVOUS SYSTEM:

CONSCIOUS,COHERENT AND COOPERATIVE

SPEECH- NORMAL

NO SIGNS OF MENINGEAL IRRITATION.

CRANIAL NERVES- INTACT

SENSORY SYSTEM- NORMAL

MOTOR SYSTEM:

TONE- NORMAL

POWER- BILATERALLY 5/5

REFLEXES: RIGHT. LEFT.

BICEPS. ++. ++

TRICEPS. ++. ++

SUPINATOR ++. ++

KNEE. ++. ++

ANKLE ++. ++

COURSE IN THE HOSPITAL:-

35 YEAR OLD FEMALE CAME TO OPD WITH ABOVE MENTIONED COMPLAINTS. NECESSARY

INVESTIGATIONS WERE DONE AND DIAGNOSED WITH IRON DEFICENCY ANEMIA SECONDARY TO NUTRITIONAL DEFICIENCY.

AT THE TIME OF ADMISSION HEMOGLOBIN WAS 3.9, 2 PRBCS WERE TRANSFUSED AND

HEMOGLOBIN IMPROVED TO 7.

1 DOSE OF IRON SUCROSE100MG IN 100 ML NS IV WAS GIVEN ON 16/4/23 AND 18/4/23.

OBGYN REFERRAL WAS TAKEN I/V/O MENORRHAGIA AND ADVICE FOLLOWED

PATIENT IS HEMODYNAMICALLY STABLE AND PLANNED FOR DISCHARGE

REFERRAL:

OBGYN OPINION:

I/V/O MENORRHAGIA AND ADVICE IS FOLLOWED

Investigation

HEMOGRAM:

12/4/2

HB: 3.9

TLC: 9,300

PCV: 16.1

RBC:2.99 MILLIONS/CUMM

PLATELETS: 8 LAKHS/CUMM

13/4/23

HB: 5.5

TLC: 11,000

PCV: 20.5

RBC: 3.48 MILLIONS/CUMM

PLATELETS: 7.4 LAKHS/CUMM

15/4/23

HB: 5.7

TLC: 5000

PCV: 22.2

RBC: 3.72 MILLIONS/CUMM

PLATELETS: 2.19 LAKHS/CUMM

17/4/23

HB: 7

TLC: 10500

PCV: 26

RBC: 4.15 MILLIONS/CUMM

PLATELETS: 4.60 LAKHS/CUMM

BLOOD TRANSFUSION:

ON 13/4/23

 1UNIT OF PRBC TRANSFUSION WAS DONE.

ON 15/4/23

1 UNIT OF PRBC TRANSFUSION WAS DONE.

USG: NO SONOLOGICAL ABNORMALITY DETECTED.

2D ECHO: MILD LVH IS PRESENT

 EF: 66%

 TRIVIAL MR+/TR+/AR+

 NO RWMA, NO AS/MS

 GOOD LV SYTOLIC FUNCTION

 NO DIASTOLIC DYSFUNCTION, NO PAH

ECG: NORMAL SINUS RHYTHM

USG:

Treatment Given(Enter only Generic Name)

INJ. IRON SUCROSE 100MG IN 100 ML NS IV/WEEKLY THRICE -- >DOSE GIVEN

INJ. NEOMOL 1 GM IV/SOS IF TEMP >101F

TAB. OROFER-XT PO/BD --> 5 DAYS

TAB. DOLO 650 MG PO/SOS

Advice at Discharge

IRON RICH DIET

TAB. OROFER-XT PO/BD --> 1 MONTH

TAB.LIMCEE 500 MGPO/OD --> 1 MONTH

TAB. DOLO 650 MG PO/SOS

OINT. THROMBOPHOBE L/A B/D--> 3 DAYS

Follow up: Limitation in physical activity and morbidly ill