Anemia with Secondary to Menorrhagia









 35 years old female, resident of Choutuppal, works in the hotel, came with 


chief complains:

SOB since 3 months , fever and generalized 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 generalized weakness since 1month ,13 days back she went to the Suryapet hospital ,there they did hemogram 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 color and non foul smelling.

-H/o heavy bleeding last month (lasted for 11 days(1st 6 days heavy bleeding then next 2 days bleeding is stopped then again 5 days bleeding occurred)

-No H/o blood in the stools, hematemesis , Malena, hemoptysis.



MENSTRUAL HISTORY:

-Regular cycle ,with normal flow until last Feb.

-Last month (March)heavy bleeding without clots ,lasted for 13 days




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

Oedema - 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 - 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        ++                  ++


PROVISIONAL DIAGNOSIS:

       Severe Anemia Secondary to Nutrition

         - Iron deficiency anemia


TREATMENT:


12/4/23  

  

  1) Tab. Dolo 650mg PO/SOS

  2) Monitor vitals 4th hourly

  3) Tab. Orofer-XT PO/OD

       o--------*--------*


INVESTIGATIONS:


  • CBP
  • CUE
  • Stools for occult blood
  • Reticulocyte count
  • Serum Iron
  • Serum Ferritin
  • USG
  • 2D-ECHO
  • ECG







13/4/23   8:00 a.m


S- no fever spikes 

    stools not yet passed


O-  O/E  Pt is c/c/c

              Temp- Afebrile on touch 

              PR- 76 bpm

              RR- 20 cpm

              BP-120/70 mmHg

              GRBS- 81 mg/dl

              I/O- 500/300 ml

              CVS- S1 S2 heard

              RS- NVBS heard

              P/A- soft, non-tender, no organomegaly

              CNS- NFND


A- Anemia secondary to menorrhagia

     ? IDA

 

P- 1) Tab. Orofer-XT   PO/OD

     2) Tab. Dolo 650mg   PO/SOS

     3) Monitor vitals 4th hourly - Temp, PR, RR, BP



14/4/23   8:00 a.m


S-  C/o leg pains

      SOB decreased

      Stools not passed

-

O-  O/E  Pt is c/c/c

               Temp afebrile on touch

               PR-89 bpm

               RR- 18 cpm

               BP- 100/70 mmHg

               GRBS- 89 mg/dl 

               CVS- S1 S2 heard, no murmurs

               RS- NVBS heard

               P/A-soft, non-tender, no organomegaly

               CNS- NFND


A-  Anemia secondary to Menorrhagia

      ? IDA

      1 PRBC Transfusion done on 13/4/23


O- O/E  Pt is c/c/c

              Temp- Afebrile on touch

              PR- 89 bpm

              RR- 18 cpm

              BP- 100/70 mmHg

              GRBS- 89 mg/dl

              CVS- S1 S2 heard, no murmurs

              RS- B/L AE +

              P/A- soft, non-tender, no organomegaly

              CNS- NFND


P- 1) Tab. Orofer-XT  PO/BD

          o--------*--------o

     2) Tab. Dolo 650mg PO/SOS

     3) Monitor vitals 4th hourly

     4) Syp. Lactulose 10 ml PO/BD

          10ml--------*--------10ml



15/4/23   8:00 a.m


S- no fever spikes

    stools passed


O-   O/E   Pt is c/c/c

                Temp- Afebrile on touch

                PR- 76 bpm

                RR- 14 cpm

                BP- 100/60 mmHg 

                CVS- S1 S2 heard, no murmurs

                RS- B/L AE + , NVBS +

                P/A- soft, non-tender, no organomegaly

                CNS- NFND


A- Severe Iron Deficiency Anemia ~ Nutritional

      1 PRBC Transfusion done on 13/4/23


P- 1) Inj. Iron Sucrose 100mg in 100ml  NS  IV/Thrice weekly

     2) Tab. Dolo 650mg PO/SOS

     3) Monitor vitals 4th hourly



16/4/23   8:00 a.m

  

S- C/o leg pains

    SOB decreased

    Stools passed


O-  O/E  Pt is c/c/c

               Temp- Afebrile on touch

               PR- 74 bpm

               RR- 18 cpm

               BP- 100/70 mmHg

               CVS- S1 S2 heard, no murmurs

               RS- B/L AE+ , NVBS

               P/A- soft, non-tender, no organomegaly

               CNS- NFND


A- Severe Iron Deficiency Anemia Sec. to Nutrition

      2 PRBC Transfusions done


P- 1) Inj. Iron Sucrose 100mg in 100ml NS IV/OD (thrice weekly)

     2) Monitor vitals 4th hourly



17/4/23   8:00 a.m


S- Fever spikes +

     

O-  O/E  Pt is c/c/c

               Temp- Febrile on touch

               PR- 78 bpm

               RR- 18 cpm

               BP- 100/60 mmHg

               CVS- S1 S2 heard, no murmurs

               RS- B/L AE + , NVBS +

               P/A- soft, non-tender, no organomegaly

               CNS- NFND


A- Severe Iron Deficiency Anemia Sec. to Nutrition

      2 PRBC Transfusions done 


P- 1) Tab. PCM 650mg PO/TID

          o--------o--------o

     2) Inj. Neomol 1gm  IV/SOS 

          (if temp > 101F)

     3)Tab. Orofer-XT  PO/OD

         *--------4pm--------*



18/4/23   8:00 a.m


S- Fever spikes +(early morning)

     Swelling and Pain on right elbow


O-  O/E  Pt is c/c/c

              Temp- Afebrile on touch 

              PR- 77 bpm

              RR- 18 cpm

              BP- 100/70 mmHg

              CVS- S1 S2 heard, no murmurs

              RS- B/L AE +, NVBS +

              P/A- soft, non-tender, no organomegaly 

              CNS- NFND


A- Severe Iron Deficiency Anemia Sec. to Nutrition

     2 PRBC Transfusions done


P- 1) Tab. Orofer-XT PO/OD

          *--------o--------*

     2) Tab. PCM 650mg PO/TID

          o--------o--------o

     3) Oint. Thrombophobe L/A BD

          o--------*--------o

     4) Vitals monitoring 4th hourly


***DISCHARGE ~ 18/4/23


ADVICE AT DISCHARGE:

  

1) Tab. Orofer-XT PO/OD

    *--------4pm--------*

2) Oint. Thrombophobe L/A  BD

3) Tab. PCM 650mg PO/SOS 

4) Tab. Limcee 500mg PO/OD










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