A 20 year old woman with anemia.
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COMPLETE URINE EXAMINATION
PERIPHERAL SMEAR
MALARIAL PARASITE
ESR
RETICULOCYTE COUNT
USG ABDOMEN
CHEST XRAY
ECG
TREATMENT :-
This elog was made under the guidance of Dr. Madhumitha .
This is a case of a 20 year old female student .
CHIEF COMPLAINT -
The patient arrived to the hospital with the complaints of
- yellowish discolouration of sclera since 6 months
- generalised weakness since 6 months
- weight loss over the last 6 months.
HISTORY OF PRESENT ILLNESS
She noticed yellowish discolouration of sclera 6 months back .She started taking a herbal medicated drink , for which she adopted a diet without meat , eggs or any dairy products for the past 6 months . Overtime, she
developed generalised weakness and even had loss of appetite and lost more than 10 kgs over the last 6 months.Her weight 8 months prior was 40 kgs .With time ,she started experiencing burning sensation in bilateral lower limbs which made it difficult for her to sleep .She is also experiencing acidity. She was taken to a local hospital outside where her -
Total bilirubin - 7g/dl
DB -3g/dl
Hb - 4g/dl
TLC -3300cells/cumm
Platelets- 1.3L/cumm
ON EXAMINATION
Patient is conscious , coherent and cooperative.
Pallor and icterus is present.
VITALS-
PR =88bpm
BP= 105/60 mmhg
RR= 14cpm
TEMP= febrile
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.
PSYCHIATRIC REFERRAL-
Patient was sent for psychiatry referral to rule out
Anorexia nervosa, Bullemia nervosa, Anxiety disorder.
IMPRESSION GIVEN BY DEPT OF PSYCHIATRY:- Adjustment disorder ( depression and anxiety secondary to general medical illness and its treatment).
Plan:- patient and mother are psychoeducated.
Individual psychotherapy session done.
Tab. Mirtaz 7.5 mg po/od.
Tab. Lomazep md 0.25 mg/po/sos ( if amxious or restless or disturbed sleep).
PERSONAL HISTORY-
No history of fever or other related infections .
Loss of appetite.
Bowels regular - No complaints of dark coloured stools.
No hematuria .
Born out of first degree consanguineous marriage .
DIETARY HISTORY-
For the past 6 months -
Vegan and restricted diet.
Before the 6 months prior to admission in the OPD -
Non - vegetarian diet
FAMILY HISTORY -
Multiple members of the family suffer from hypertension.
PROVISIONAL DIAGNOSIS :-
MEGALOBLASTIC ANEMIA WITH ADJUSTMENT DISORDER (DEPRESSION AND ANXIETY)
INVESTIGATIONS
HEMOGRAM
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.
4)Date - 3.7.2021
•Inj. Pan 40mg IV/OD
• Tab. Folic acid 5mg PO/OD.
• Tab. Zincovit PO/OD.
• Inj. Vitcofol 1amp IM/BD.
5)Date - 4.7.2021
•Inj. Pan 40mg IV/OD
• Tab. Folic acid 5mg PO/OD.
• Tab. Zincovit PO/OD.
• Inj. Vitcofol 1amp IM/BD.
6) Date - 5.7.2021
•Inj. Pan 40mg IV/OD
• Tab. Folic acid 5mg PO/OD.
• Tab. Zincovit PO/OD.
• Inj. Vitcofol 1amp IM/BD.
7) Date - 6.7.2021
•Inj. Pan 40mg IV/OD
• Tab. Folic acid 5mg PO/OD.
• Tab. Zincovit PO/OD.
• Inj. Vitcofol 1amp IM/BD.
8) Date - 7.7.2021
•Inj. Pan 40mg IV/OD
• Tab. Folic acid 5mg PO/OD.
• Tab. Zincovit PO/OD.
• Inj. Vitcofol 1amp IM/BD.
9) Date - 8.7.2021
•Inj. Pan 40mg IV/OD
• Tab. Folic acid 5mg PO/OD.
• Tab. Zincovit PO/OD.
• Inj. Vitcofol 1amp IM/BD.
10) Date- 9.7.2021
Advice at discharge:
1) Inj Vitcofol 1amp IM every week for 4 weeks.
2) Tab.Riboflavin 10mg PO/BD for 1 month
3) Tab Zincovit PO/OD for 1 month.
4) Tab.Orofer XT PO/BD for 1 month (before food)
5) Tab Limcee PO/OD for 1 month (before food)
6) Daily 1egg/day.
7) Tab. Pregabalin 75mg SOS
COURSE IN THE HOSPITAL:-
This is a case of a 20yr old female with anaemia secondary to deficiency of Vitamin B12 and Folic acid.( Megaloblastic anemia).The patient was admitted one week back and was treated with Inj Vitcofol For B12 , Folic acid supplementation , Tab Riboflavin 10mg BD , and Tab Zincovit for multivitamin supplementation every day and was advised discharge and review to the OPD after 15 days.
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/BD.
4)Date - 3.7.2021
•Inj. Pan 40mg IV/OD
• Tab. Folic acid 5mg PO/OD.
• Tab. Zincovit PO/OD.
• Inj. Vitcofol 1amp IM/BD.
5)Date - 4.7.2021
•Inj. Pan 40mg IV/OD
• Tab. Folic acid 5mg PO/OD.
• Tab. Zincovit PO/OD.
• Inj. Vitcofol 1amp IM/BD.
6) Date - 5.7.2021
•Inj. Pan 40mg IV/OD
• Tab. Folic acid 5mg PO/OD.
• Tab. Zincovit PO/OD.
• Inj. Vitcofol 1amp IM/BD.
7) Date - 6.7.2021
•Inj. Pan 40mg IV/OD
• Tab. Folic acid 5mg PO/OD.
• Tab. Zincovit PO/OD.
• Inj. Vitcofol 1amp IM/BD.
8) Date - 7.7.2021
•Inj. Pan 40mg IV/OD
• Tab. Folic acid 5mg PO/OD.
• Tab. Zincovit PO/OD.
• Inj. Vitcofol 1amp IM/BD.
9) Date - 8.7.2021
•Inj. Pan 40mg IV/OD
• Tab. Folic acid 5mg PO/OD.
• Tab. Zincovit PO/OD.
• Inj. Vitcofol 1amp IM/BD.
10) Date- 9.7.2021
Advice at discharge:
1) Inj Vitcofol 1amp IM every week for 4 weeks.
2) Tab.Riboflavin 10mg PO/BD for 1 month
3) Tab Zincovit PO/OD for 1 month.
4) Tab.Orofer XT PO/BD for 1 month (before food)
5) Tab Limcee PO/OD for 1 month (before food)
6) Daily 1egg/day.
7) Tab. Pregabalin 75mg SOS
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