19 YR OLD FEMALE PATIENT ANEMIA UNDER EVALUATION

 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.Nikhil 

1701006013

19 YR OLD FEMALE PATIENT CAME TO CASULAITY WITH CHEIF COMPLAINT OF 

FEVER SINCE 3 DAYS 

SOB SINCE 2  DAYS 

HOPI:- 

Patient was apparently asymptomatic 1 month back she developed increased menstrual bleeding  for 9 days @ 4-5 days not associated with clots and dysmenorrhea .patient have similar complaints in this cycle no clots no pain 2 -3 pads . fever since 3 days low grade intermittent not a/w chills and rigors not a/w cold and cough , burning micturation , loose stools relieved on taking medications no body pains 

Sob insidious in onset non progressive grade 2 (mmrc) not a/ w postural variation (no orpthopnea , platypnea , pnd) not a/w syncope palpitations .

Chest pain increased with exertion relived at rest pt was taken to private hospital and was decteted to have (HB- 1.9 , TLC- 10,800 , PLT- 18000 , Pcv -8.1 , ESR-35) and was referred here for blood transfusion  

NO H/O black stools, hematemesis, bleeding, no previous blood transfusion 

PAST HISTORY:- 

Not a k/c/o DM, HTN,ASTHMA, TB , CAD, epilepsy ,THYROID 

FAMILY HISTORY:- 

no significant family history 

PERSONAL HISTORY:-

DIET-  mixed

APPETITE- normal

BOWEL AND BLADDER- regular

SLEEP- adequate 

GENERAL EXAMINATION:-

Pt is c/c/c 

PALLOR - present 






No icterus , cyanosis , clubbing , lymphadenopathy, edema 

VITALS ON EXAMINATION 

BP-110/80mmhg 

PR-110 bpm

RR-26 cpm

P/A- soft non tender 

Temp-99 f

SYSTEMIC EXAMINATION:- 

CVS - S1 S2 + no murmurs 

RS  -   BLAE +

P/A-  soft, non tender

CNS - NAD

INVESTIGATION:-

HEMOGRAM:- on 30-9-22



On 1-10-22



ON 2-10-22

On 3-10-22



BLOOD GROUPING AND RH TYPING 



PERIPHERAL SMEAR:-


RETICULOCYTE COUNT:-


ESR:- 

PT:-



APTT:-



BLOOD FOR M.P STRIP TEST:-


CUE:-


SERUM IRON:-



SERUM ELECTROLYTES:-

SERUM IRON:-

LDH

LFT:- 

BLOOD UREA:-

ECG

                          2D ECHO:-

       SEROLOGY:-
             





PROVISONAL DIAGNOSIS:-

SEVERE IRON DEFICIENCY ANEMIA ?  NUTRITIONAL WITH THROMBOCYTOPENIA


TREATMENT:-

1) INJ. IRON SUCROSE (100 mg +100 ml NS ) IV OD 

2 ) 1 UNIT OF PRBC BLOOD TRANSFUSION DONE 

3)  1 UNITS OF SDP  TRANSFUSION DONE

ON 1-10-22

1 UNIT OF PRBC BLOOD TRANSFUSION DONE

 ON 2-10-22

1. 1 UNITS OF SDP  TRANSFUSION DONE

2.


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