IRON DEFICIENCY ANEMIA TO BLOOD LOSS (ANAL FISSURE)

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.

Follow up:No limitation in physical activity

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