IRON DEFICIENCY ANAEMIA

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A 17 year old female patient came with chief complaints of shortness of breath on exertion since 2 months 

HISTORY OF PRESENT ILLNESS :- 

patient was apparently asymptomatic  2 months ago then she developed  shortness of breath on exertion  grade 2. she wanted to get covid vaccine  2 days back so she got blood investigations doneshe had hemoglobin 2.3 gm/dl

she complains of generalized weakness 

c/o palpitations since 2 months 

no meleana / hemorroidhs 

no past h/o surgeries 

she attained menarche  1 year ago

3-5 /30 , 2-3 pads/day 

one unit of prbs was done on the day of admission 

One unit of prbs was given on 2/3/22

no pain , no clots

PAST HISTORY :- 

No h/o similar complaints in the past

no  past h/0 of blood transfusion 

N/k/c/o Asthma , Hypertension,DM, Epilepsy 

PERSONAL HISTORY 

Sleep:adequate

Appetite:decreased

Diet:mixed 

Bowel and bladder movements:constipation

GENERAL PHYSICAL EXAMINATION 

Patient was conscious , coherent , co-operative , moderately built and nourished , well oriented to time place and person

 Pallor - present

 Icterus - absent

 Cyanosis - absent

 Clubbing - absent

 Lymphadennopathy absent

 Edema - absent

VITALS:

temp:97.3F

PR: 98 bpm

BP: 110/50 mm hg

RR:16 cpm

spo2 :99%

SYSTEMIC EXAMINATION 

CVS :s1 , s2 heard 

RS: bilateral air entry present

P/A.  soft non tender 

spleen palpable in left hypochondriac region

CNS.no focal or neutral deficits

       

INVESTIGATIONS :- 

HB :2.3 gm/dl

TLC 3,400 cells/cumm

PLT. 1.70 lakh cells/cumm

anisopoikilocytosis with microcytic hypochromic , tear  drop RBCs

BGT.  B positive 

reticulocyte count. 1%

28/2/22

ESR. 20 

LFT :- 

TB. O.98 

DB 0.24 

SGOT   26 

SGPT.    17 

ALP  201 

TP  7.4 

ALBUMIN  4.5 

A/G RATIO. 1.54 

RFT 

SR UREA. 1.6 

SR.  CREATINE 0.5

URIC ACID. 2.3 

NA+. 140 

K+. 4.0 

CL-  102 

SR FE.  50 

1 /3/22 

hb 5.1 g/dl 

tlc.  2500/mm3 

plt.  1.5 lakhs /mm3 

PROVISIONAL DIAGNOSIS 

IRON DEFICIENCY ANEMIA 

5/3/22

TREATMENT

1) INJ NERVIGEN 1AMP IN 100 ML NS IV OD

2) TAB OROFER XT PO OD 

3) TAB MATIDA FORTE PO OD