58/F WITH ANEMIA(? NUTRITIONAL)
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Unit 6:
Case admitted in female ward on 6/2/2021.
Interns
K.Divya Rachana
K. Nikhil reddy
M. Swarna
B.Manivarma
Juveria
Dr. Vinay(pgy1)
Dr. Rashmitha(pgy2)
Dr. A. Vaishnavi (pgy2)
Dr. Sai Radha(pgy3)
Dr. Hareen (SR)
Dr. Arjun Kumar(asst.proff)
Dr.Praveen Naik( asst.proff)
A 56 YEAR OLD FEMALE CAME TO THE OP WITH COMPLAINTS OF-
SHORTNESS OF BREATH
EASY FATIGUABILITY
DECREASED APPETITE SINCE 1 MONTH
SHORTNESS OF BREATH IS GRADE IV, GRADUAL IN ONSET, PROGRESSIVE IN NATURE ASSOCIATED WITH PEDAL EDEMA-PITTING TYPE,NON TENDER EXTENDED UPTO SHIN OF TIBIA.
NOT ASSOCIATED WITH CHEST PAIN, PALPITATIONS, DECREASED URINE OUTPUT, SWEATING.
HISTORY OF FEVER-LOW GRADE ON/OFF SINCE 1 MONTH.
PATIENT WAS APPARENTLY ASYMPTOMATIC 8 YEARS BACK,THEN SHE DEVELOPED BLEBS OVER HER B/L HANDS FOR WHICH SHE WENT TO THE HOSPITAL WHERE HER HB WAS FOUND OUT TO BE LOW AND THEN THEY TRANSFUSED 1 PINT OF BLOOD.ATTENDERS GAVE A HISTORY THAT SHE HAD BLOODY STOOLS OF 4-6 EPISODES,THEN SHE WAS TREATED WITH IV FLUIDS.TWO YEARS BACK HER HUSBAND EXPIRED AND SINCE THEN SHE HAD A DECREASED APPETITE.
SINCE 1 MONTH SHE HAS BEEN TAKING JUST CURD RICE EVERYDAY.
H/O WEIGHTLOSS PRESENT
NO H/O DM,HTN,ASTHMA,CAD,TB, THYROID DYSFUNCTION.
SHE'S A HOMEMAKER WITH DECREASED APPETITE SINCE 2 YEARS.SHE CONSUMES VEGETARIAN DIET, REGULAR BLADDER AMS BOWEL MOVEMENTS.
NO ADDICTIONS
SHE ATTAINED MENOPAUSE 20 YEARS BACK
ON EXAMINATION
SHE HAS SEVERE PALLOR
PEDAL EDEMA-PITTING TYPE UPTO KNEE.
NO ICTERUS, CYANOSIS,CLUBBING, LYMPHADENOPATHY.
TEMP-98 F
PR-117 BPM
BP-110/70 MM OF HG
SPO2-98 @ ROOM AIR
CVS-
S1 S2 HEARD
VENOUS HUMP +
PAN SYSTOLIC MURMUR PRESENT IN AORTIC, TRICUSPID,MITRAL AREA
RS-DIFFUSE COARSE CREPTS DURING INSPIRATION
P/A-SOFT,NON TENDER
CVS-NAD
PROVISIONAL DIAGNOSIS-
ANEMIA (? NUTRITIONAL DEFICIENCY ) WITH MILD THROMBOCYTOPENIA
TREATMENT-
DAY 1-
1 UNIT PRBC TRANSFUSED
INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD
SYP ASCORIL-D 15 ML/PO/TID
TAB PAN D PO/OD
TAB PCM 500 MG PO/SOS
NEBULIZATION WITH MUCOMIST-12TH HRLY
SYP CREMAFFIN 15 ML/PO/BD
HIGH PROTEIN DIET
DAY 2-
INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD
SYP ASCORIL-D15 ML/PO/TID
TAB PAN D PO/OD
TAB PCM 500 MG PO/SOS
NEBULIZATION WITH MUCOMIST-12TH HRLY
SYP CREMAFFIN 15 ML/PO/BD
HIGH PROTEIN DIET
DAY 3-
INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD
SYP ASCORIL-D 15 ML/PO/TID
TAB PAN D PO/OD
TAB PCM 500 MG PO/SOS
NEBULIZATION WITH MUCOMIST-12TH HRLY
SYP CREMAFFIN 15 ML/PO/BD
HIGH PROTEIN DIET
