A CASE OF IRON DEFICIENCY PRESENTED IN SUMMER OF 2023


  • The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed consent. 


  • Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.



  • This E-log also reflects my patient's centered online learning portfolio.



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 and a resident of Narketpalley 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 II) . 

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 .

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