Iron deficiency Anemia

17/F 



patient came with chief complaints of sob on exertion since 2 months 

HISTORY OF PRESENT ILLNESS :- 

patient was apparently asymptomatic 2 months ago then she developed sob on exertion grade 2. she went to get covid vaccine 2 days back and when she got blood investigations she got hemoglobin 2.3 

she complaints of chest pain on and off since 2 months 

she complains of generalized weakness 

c/o palpitations since 2 months 

no meleana / hemorroidhs 

no past h/0 surgeries 

she attained menarche 6 months ago 

3-5 /30 , 2-3 pads/day fully soaked 



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 past h/0 of blood transfusion 

N/k/c/o asthma , htn, dm , epilepsy 



on examination :- 

patient was conscious , coherent , co operative 

pallor present

cyanosis, icterus , lymphadenopathy, edema , are absent 



vitals :- 

temp 97.3F

PR. 98 bpm

bp 110/50 mm hg

RR. 16cpm

spo2 99%



systemic examination:- 



CVS . s1 , s2 heard 

RS. bilateral air present 

P/A. soft non tender 

Mild hepatomegaly , splenomegaly

CNS. Intact 

            gcs 15/15 

           motor system intact 

           sensory system intact 

           reflexes. normal 

INVESTIGATIONS :- 

HB :2.3 

TLC 3,400

PLT. 1.70 

anisopoikilocytosis with microcytic hypochromic , tear  drop , 

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

7th day of admissionS: no complaints 


O: O/E pt is c/c/c 


Vitals: PR-104bpm


            BP-110/70 mm Hg 


            CVS- s1s2 +


            RS- BAE+ 


                           Pt. Normal 


Menarche 16yr 12-14y


Pubarche + 16y 12-14


Thelarche + 15y 11-11.5y


Axillary hair Absent


Wt: 33.5kg


Ht: 151cm






A: IRON DEFICIENCY ANEMIA HEPATOSPLEENOMEGALY+


DELAYED PUBERTY (absence of thelarche by 13 y) 


? SECONDARY TO NUTRITIONAL CAUSE




P: 


Inj NERVIGEN 1amp in 100ml NS IV OD


T. OROFER PO OD


T. NEUROBION FOR PO/OD


T. ZINCOVIT 




TOTAL IRON DEFICIT 826mg


INJ IRON SUCROSE 200 mg in 100 ml NS over 1 hr

 

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