1. MAJOR CASE PRESENTATION ON SEVERE ANEMIA

2. SCENARIO:
Here is a 60 years old male patient admitted in medicine male ward
diagnosed 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.

3. LABORATORY INVESTIGATIONS:
Peripheral smear: Macrocytic anemia
test
Patient value
Normal value
RBC
1.38 million/μl
million/μl
WBC
2690 cumm
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
Sr.Bilirubin conjugated
1.0
mg/dl
Unconjugated
mg/dl

4. GENERAL PHYSICAL EXAMINATION
Pallor + +
Scelera in yellowish colour
Icterus +
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.

5. 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 function
Hb is drastically decreased which indicates severe anemia
ESR is increased due to infection
PCV 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 damage
Sr bilirubin values are increased that indicates there may be a liver damage
Peripheral smear shows macrocytic anemia.

6. Diagnosis: By observing the above subjective and objective data the patient is diagnosed with severe anemia.
ASSESSMENT:
Problem list:
1.Weakness
2.Loss of appetite
3.Severe anemia
Weakness: Due to anemia the patient feels weak.
Loss of appetite: It is due to anemia
Severe 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.

7. PLAN OF CARE:
GOALS OF THERAPY:
To alleviate signs and symptoms
Correcting the underlying etiology
Prevent reoccurence of anemia.

8. S.no
Brand name
Generic name
Dose &
freuency
Day 1 2 3 4 5 1.
Inj.Vomikind iv
ondansetron
1-1-1
20mg Y 2.
Inj.Pantodac
pantoprazole
40mg
1-0-0 Tb 3.
Tb. Anxit
alprazolam
0.5mg
0-0-1 4.
Cp.Omegapace
0-1-0 5.
Inj.Orofer S
Iron sucrose
In 100ml NS 6.
Inj.Vitcofol im
Folic acid ,multi vit,Ferrous sulphate
2cc 7.
Inj.Divon im
Diclofenac Na
s-o-s 8.
Syp.orofer Xt
Elemental iron

9. Drug-drug interactions:
Ferrous sulphate + Pantoprazole – reduces absorption of iron
Monitor 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 x 15 days
2. syp. Fesovit x 15 days
3. Tab. Anxit 0.5mg x5 days
4. cap. Omegapace 0-1-0

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