Iron deficiency anemia

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box. 


 A 17 year old female patient came with chief complaints of shortness of breath on exertion since 2 months.


History of presenting illness

Patient was apparently asymptomatic 2 months ago then she developed shortness of breath on exertion ie; grade 2. She wanted to get covid vaccination 3 days back so she got blood investigations done. He had a hemoglobin 2.3gm/DL
She complains of having generalized weakness  and palpitations since 2 months
No meleana / hemorrhoids 
no past history of surgeries 
she attainment 1 year ago 
3-5  days /30 days , 2-3 pads/day
1 unit of pc RBC question on the day of admission and another was done on on 2/03/2022, no pain and clots 


 Past history

No / H/of similar complaints in the past 
no history of past blood transfusions 
not a known case of asthma hypertension TB epilepsy and diabetes

Personal history

Appetite:decreased
Diet:mixed 
Bowel and bladder movements:constipation

ON EXAMINATION:

Patient was conscious , coherent , cooperative 
pallor -  present



cyanosis, icterus , lymphadenopathy, edema  are absent


VITALS:

temp:97.3F
PR: 98 bpm
BP: 110/50 mm hg
RR:16 cpm
spo2 :99%


SYSTEMIC EXAMINATION 

CVS : s1 , s2 heard 
RS : bilateral air entry present
P/A : soft  and non tender 
spleen palpable in left hypochondriac region
CNS : no focal or neurological deficits
       

INVESTIGATIONS :- 

HB :2.3 gm/dl
TLC : 3,400 cells/cumm
PLT : 1.70 lakh cells/cu mm
anisopoikilocytosis with microcytic hypochromic , tear  drop RBCs
BGT : B positive 
reticulocyte count : 1%






28/02/22
ESR : 20 

LFT :- 
TB : O.98 
DB : 0.24 
SGOT:  26 
SGPT :  17 
ALP : 201 
TP : 7.4 
ALBUMIN : 4.5 
A/G RATIO : 1.54 

RFT :-
SR UREA : 1.6 
SR.  CREATINE : 0.5
URIC ACID : 2.3 
Na+ : 140 
K+ : 4.0 
Cl- : 102 
Serum Fe : 50 

1 /3/22 
hb : 5.1 g/dl 
TLC :  2500/mm3 
platelets : 1.5 lakhs /mm3 





PROVISIONAL DIAGNOSIS 

IRON DEFICIENCY ANEMIA



Treatment 

1) INJ NERVIGEN 1AMP IN 100 ML NS IV OD
2) TAB OROFER XT PO OD 
3) TAB MATIDA FORTE PO OD

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