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A CASE OF ANEMIA

A 20 year old female patient came to OPD  , she is a student. 

Her chief complaints are:

Yellow discoloration of sclera

Burning sensation b/w lowerlimbs

Weakness

Loss of appetite

Weight loss

All these complaints are since 6months 

HOPI:

 The patient had all the above complaints since 6months and she was asymptomatic 6months ago. She started taking herbal medicine when she developed yellowish discoloration for 2days and stopped . 

History of Burning sensation b/w lower limbs is seen over a period of time. 

Weakness and weight loss around 10 to 12 kgs is also seen. Patient also gives history of passing dark colored stools sometimes. 

Past history

No h/o fever 

No h/o drug intake 

No h/o hematuria

No h/o rashes 

2 days back she gives h/o visiting local hospital and the tests done are 

Total bilirubin- 7g/dl

Direct bilirubin- 3g/dl

Hemoglobin- 4g/dl

TLC- 3300

Platelets - 1.3 L / cumm

GENERAL EXAMINATION:-

Patient is Conscious, Coherent, Cooperative

Pallor is present

Icterus is present

SYSTEMIC EXAMINATION:-

Vitals- PR =88bpm

            BP= 105/60 mmhg

            RR= 14cpm

            TEMP= afebrile 

            SPO2= 100% at room air.

CVS:-

S1, S2 heard 

Palpable P2

Parasternal heave is present. 

RESPIRATORY SYSTEM :-

BAE+

NVBS heard

PER ABDOMEN :-

Shape of the abdomen is scaphoid. 

Tenderness is present in Right hypochondrium. 

Liver and spleen are not palpable. 

Bowel sounds are heard.

CNS :-

Patient is conscious. 

Speech is normal.

No signs of meningeal irritation. 

Reflexes are normal.

PROVISIONAL DIAGNOSIS  :-

Anemia with indirect hyperbilirubinemia under evaluation.

INVESTIGATIONS:-

HEMOGRAM

CUE

PERIPHERAL SMEAR

MALARIA PARASITE

ESR

RETICULOCYTE COUNT

USG ABDOMEN

ECG

CXR

TREATMENT :-

1)Date- 30.6.2021

• Inj. Pantop 40mg IV/OD.

• Monitor vitals

• Strict I/O charting.

2) Date - 1.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/OD.

3) Date - 2.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/OD

DISCHARGE TEMPLATE:- 

1)Date- 30.6.2021

• Inj. Pantop 40mg IV/OD.

• Monitor vitals

• Strict I/O charting.

2) Date - 1.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/OD.

3) Date - 2.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/OD.