MAJOR CASE PRESENTATION ON SEVERE ANEMIA

SCENARIO: Here is a 60 years old male patient admitted in medicine male ward diagnosed as Severe anemia was hospitalised for 5 days. CHIEF COMPLAINTS: c/o weakness since 1month c/o loss of appetite since 1 month HISTORY OF PRESENT ILLNESS: Patient was apparently normal one month back then the patient started to feel weakness which was gradual in onset & progressive in nature .patient get easily tired & feels shortness of breath when walking for 30 to 100 meters. Patient feels sleepy & weak throught the day, Patient also has loss of appetite do not have interest in eating and eats small qty.

LABORATORY INVESTIGATIONS: Peripheral smear: Macrocytic anemia test Patient value Normal value RBC 1.38 million/μl 4.5-6.2 million/μl WBC 2690 cumm 4000-11000 cumm Hb 7.5 g/dl 12-16g/dl ESR 75 mm/hr <10 mm/hr PCV 15.4 % 41-50% Platelet count 0.95 cell/cumm 1-3 lakhs cell/cumm MCV 111.6 fl 80-100fl MCH 39.1 9/dl 32-26g/dl SGOT 247 <40 SGPT 56 Sr.Bilirubin conjugated 1.0 0.1-1.2mg/dl Unconjugated 0.2-0.7mg/dl

GENERAL PHYSICAL EXAMINATION Pallor + + Scelera in yellowish colour Icterus + Bone marrow aspiration done twice but the needle was blocked with fat unable to aspirate the marrow. SOAP NOTE: Subjective: Here is a 60years old male presenting complaints of weakness and Loss of appetite since 1 month.

Objective: RBC is decreased that indicates anemia. WBC is decreased which implies diminished bone marrow function Platelet count is reduced due to diminished bone marrow function Hb is drastically decreased which indicates severe anemia ESR is increased due to infection PCV is decreased that indicates over hydration or due to anemia. MCV & MCH values are increased which indicates macrocytic hyperchromia. SGOT & SGPT levels are increased that indicates liver damage Sr bilirubin values are increased that indicates there may be a liver damage Peripheral smear shows macrocytic anemia.

Diagnosis: By observing the above subjective and objective data the patient is diagnosed with severe anemia. ASSESSMENT: Problem list: 1.Weakness 2.Loss of appetite 3.Severe anemia Weakness: Due to anemia the patient feels weak. Loss of appetite: It is due to anemia Severe anemia : It is due to decrease in the amount of RBC or the amount Hb in the blood. It can be defined as the lowered ability of the blood to carry oxygen. It can be due to nutritional defeciencies.

PLAN OF CARE: GOALS OF THERAPY: To alleviate signs and symptoms Correcting the underlying etiology Prevent reoccurence of anemia.

S.no Brand name Generic name Dose & freuency Day 1 2 3 4 5 1. Inj.Vomikind iv ondansetron 1-1-1 20mg Y 2. Inj.Pantodac pantoprazole 40mg 1-0-0 Tb 3. Tb. Anxit alprazolam 0.5mg 0-0-1 4. Cp.Omegapace 0-1-0 5. Inj.Orofer S Iron sucrose In 100ml NS 1-0-1 6. Inj.Vitcofol im Folic acid ,multi vit,Ferrous sulphate 2cc 7. Inj.Divon im Diclofenac Na s-o-s 8. Syp.orofer Xt Elemental iron

Drug-drug interactions: Ferrous sulphate + Pantoprazole – reduces absorption of iron Monitor CBC for the normal levels RBC,Hb Patient counselling: Patient is adviced to take iron rich diet such as green leafy vegetables, fruits, egg, liver, kidney etc, Discharge drugs: 1.Cap.Vitcofol 1-0-1 x 15 days 2. syp. Fesovit 0-1-1 x 15 days 3. Tab. Anxit 0.5mg 0-0-1 x5 days 4. cap. Omegapace 0-1-0

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