45yr old Female with Severe Anemia

45 yr old female with Severe Anemia

Name- K. Medha Reddy

Roll.no- 51

Batch-2017

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CASE:

Icu bed 2 

45 year old female who is a housewife survived with 3 kids came to casualty with complaints of Vomitings ( food particle as content , non bilious , non projectile ) Since yesterday there were 10 episodes 

- C/O giddiness 

Hopi:- Patient was apparently assymptomatic 1 month back then she had decreased appetite since 1 month 

- C/O weight loss since 1 month 

- C/O Shortness of breath ( grade 2 - grade 3 ) according to NYHA Classification, not associated with Orthopnea / PND

- H/O Heavy bleeding since 10 days (3-4 pads/day) 

- C/O B/L Pedal edema since 10 days 

 

Past history :- 

- H/O similar complaints in the past diagnosed with megaloblastic anemia in the year 2007 

- H/O Hemorrhoids in the year 2014

- H/O Recurrent Blood Transfusion since 2014

- Not a k/c/o DM/ HM/ Asthma / Epilepsy

Personal history:-

Married female 

Appetite - Normal

Diet :- mixed 

Bowels:- regular

Micturition:- normal 

- No addictions 

Family history:- Not significant 

General examination:-

Patient is conscious , coherent , cooperative

- oriented to time , place , person

 

- Pallor +

- No icterus , clubbing , cyanosis , odema, lymphadenopathy 

VITALS:-

Temp:- 98.5 

PR:- 112/min

RR:- 18/min

BP:- 90/60mmhg

SPO2:- 99%

GRBS:- 105mg %

Systemic examination:-

CVS:- S1S2 + PANSYSTOLIC Murmurs + Raised JVP

RS:- BAE + , No crepts 

P/A:- Splenomegaly + 

CNS:- Intact

Provisional diagnosis :- 

Anemia under evaluation 

? Megaloblastic anemia 

Investigations:- 

Serum LDH:- 4294 IU/L

Serum IRON:- 30 mg/dl

Serum electrolytes :-

Na:- 131 meq/L

K:- 3.9 meq/L

Cl:- 99 meq/L

Blood urea :- 18mg/dl

Creatinine :- 0.6 

CRP:- Negative 

Usg abdomen and pelvis :- 

Impression - 

mild splenomegaly 

2D ECHO:- 

Impression:- 

EF:- 60%

Rvsp:- 45mmhg 

- IVC Size ( 0.9cms ) collapsing 

- Moderate to severe MR, Mild TR + with PAH? , Trivial AR +

- NO RWMA , NO AS/MS , Sclerotic AV

- Good Lv systolic function 

- Diastolic Dysfunction ++ , No PE

LFT:-

TB:- 1.87 mg/dl

DB:- 0.42 mg/dl

AST:- 106 IU /L

ALT:- 18 IU/L

ALP:- 102 IU / L

TP:- 4.9 gm/dl

Albumin:- 2.9 gm/dl

A/G :- 1.49

Management :- 

1) Tab ZOFER 4mg IV/ SOS

2) Inj NEOMOL 100ml ( if temp greater than 101.1 )

3) Inj PAN 40mg IV/ OD

4) Monitor Vitals Hrly

SOAP NOTES 

Day 2 

ICU BED 2 

S:- 

- C/O Burning Micturition 

- No vomiting episodes

- No giddiness 

- SOB reduced 

O:- 

Patient is conscious , coherent , cooperative 

- oriented to time , place , person 

Temp:- 97.3

PR:- 104

BP:- 90/60

RR:- 18 cpm

SPO2 :- 98%

GRBS:- 104mg/dl

CVS:- S1S2 + , No murmurs

RS:- NVBS + , No crepts 

P/A :- Splenomegaly +

A:- Anemia secondary to ? nutritional deficiency ( B12) 

P:- 

1) Inj METHYLCOBALAMINE 1500mg in 50ml NS/IV / OD

2) Inj PAN 40mg IV/OD

3) Inj ZOFER4mg IV/SOS

4) Inj NEOMOL 100ml ( if temp > 101.1) 

5) Inj TRANEXAMIC ACID 1 Amp / IV/BD

6) Monitor Vitals Hrly