MAJOR CASE PRESENTATION ON - PowerPoint Presentation

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MAJOR CASE PRESENTATION ON SEVERE ANEMIA

SCENARIO:

Here is a 60 years old male patient admitted in medicine male ward

d

iagnosed 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/

μ

l

4.5-6.2 million/

μ

l

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

<40

Sr.Bilirubin

conjugated

1.0

0.1-1.2mg/dl

Unconjugated

1.0

0.2-0.7mg/dl

GENERAL PHYSICAL EXAMINATION

Pallor + +

Scelera

in yellowish colourIcterus + 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 functionHb is drastically decreased which indicates severe anemiaESR is increased due to infectionPCV 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 damageSr 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.Weakness2.Loss of appetite3.Severe anemiaWeakness: Due to anemia the patient feels weak.Loss of appetite: It is due to anemiaSevere 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 nameDose & freuencyDay123451.Inj.Vomikind ivondansetron1-1-120mg YY

Y

Y

2.

Inj.Pantodac

pantoprazole

40mg

1-0-0

Y

Y

Y

Tb

Y

Y

3.

Tb.

Anxit

alprazolam

0.5mg

0-0-1

Y

Y

Y

Y

Y

4.

Cp.Omegapace

0-1-0

Y

Y

Y

Y

Y

5.

Inj.Orofer

S

Iron sucrose

In 100ml NS

1-0-1

Y

Y

Y

Y

Y

6.

Inj.Vitcofol

im

Folic acid ,multi

vit,Ferrous

sulphate

2cc

0-1-0

Y

Y

Y

Y

Y

7.

Inj.Divon

im

Diclofenac Na

s-o-s

Y

Y

Y

8.

Syp.orofer

Xt

Elemental iron

1-1-1

Y

Y

Y

Drug-drug interactions:

Ferrous sulphate +

Pantoprazole

– reduces absorption of ironMonitor 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

THANKING YOU