A CASE OF IRON DEFICIENCY PRESENTED IN SUMMER OF 2023
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I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and providing treatment best to our skills and wisdom.
A 40yr old patient who is a housewife presented to the casualty with complaints of pedal edema , generalised weakness and breathlessness.
Date of Admission: 07/06/23
CHIEF COMPLAINTS
➤ B/L pedal edema (on and off) since 15 days
➤ Generalised weakness since 15 days .
➤ SOB since 1 week .
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 15 days ago . Then she developed c/o pedal edema till ankle that was pitting , on and off type , relieved at night .
She had c/o facial puffiness 10 days ago that was relieved after waking up .
Then she developed SOB on doing ordinary activity (Grade III ) .
No c/o chest pain , palpitations, orthopnea , PND, decreased input output.
HISTORY OF PAST ILLNESS
➤ Not a k/c/o diabetes mellitus, HTN , TB epilepsy , asthma ,CAD , thyroid disorders.
PERSONAL HISTORY
➤Occupation: Housewife
➤Patient is married .
➤Patient takes a mixed diet and has a normal appetite.
➤Sleep : Regular
➤Bowel movements are regular , micturition normal .
➤No known allergies .
➤ No known addictions -
➤ No h/o surgery or blood transfusion.
FAMILY HISTORY
Not significant .
GENERAL EXAMINATION
➤Pallor : seen
➤Icterus : not seen
➤Cyanosis : not seen
➤Clubbing : not seen
➤Lymphadenopathy : not seen
➤Edema : not seen .
VITALS
➤ Afebrile
➤PR : 89 beats per minute
➤BP : 110/70 mm Hg
➤RR : 18 cycles per minute
➤SpO2 : 98% in room air
➤ GRBS : 132 mg/dl
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM EXAMINATION
➤s1 and s2 heard
➤Thrills absent.,
➤No cardiac murmurs
RESPIRATORY SYSTEM
➤Normal vesicular breath sounds heard.
➤Bilateral air entry present
➤Trachea is in midline.
➤ Breath sounds - vesicular
ABDOMINAL EXAMINATION
INSPECTION
➤Shape - Scaphoid
➤Equal movements in all the quadrants.
➤No visible pulsation, dilated veins and
localized swellings.
PALPATION
➤Liver , spleen not palpable.
➤ Epigastric tenderness .
CENTRAL NERVOUS SYSTEM EXAMINATION
➤Conscious and coherent
➤Speech : Normal
➤No signs of meningeal irritation
PROVISIONAL DIAGNOSIS: IRON DEFICIENCY ANEMIA
TREATMENT
1. Inj. Optineuron 1ampuole
2. Inj. Iron Sucrose 200mg in 100ml NS IV/OD.
3. Tab. Metformin 500mg PO/BD.
4. GRBS profile monitoring .
