20 year old female with Anemia?

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"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment"

A 20 yrs old female was brought to the casualty with the C/O easy fatigability since 3 months.
C/O Shortness of breath (grade 3 ) since 3 months.
C/O loss of appetite since 3 months.
HOPI:-
Patient was apparently asymptomatic 3 months ago,then she developed Shortness of breath (grade 3)which is not associated with orthopnea /PND.
C/O easy fatigability since 3 months.
C/O loss of appetite since 3 months.
Not associated with melena, haematemesis,pica,weight loss.
PAST HISTORY:
Not a k/c/o DM/HTN/ASTHMA/TB/CAD/CVD

FAMILY HISTORY:
Not significant.
GENERAL EXAMINATION:
Pt is conscious, coherent, cooperative
Bp-110/80 mmHg
PR-71bpm
Temp -98.5°F
SpO2- 98%@RA
GRBS -98mg% @admission

CVS : S1 S2 +, Apex beat : 5th ICS mid clavicular line.
Murmur +:pansystolic murmur @ Pulmonary area

RS : BAE +

CNS : NAD

P/A : Soft, no tenderness . Bowel sounds +
Spleen palpable+

Pallor ++


No icterus
No clubbing
Koilonychia present
No lymphadenopathy
No edema
Hyperpigmentation of knuckles+

PROVISIONAL DIAGNOSIS:
Iron deficiency Anemia
?B12 deficiency


Laboratory findings:
Treatment given:
1.INJ.PANTOP 40 MG/IV/OD
2.INJ.NEOMOL 100 ML( IF TEMP >101.1F)
3.TAB.PCM 500MG/PO/SOS
4.MONITOR TEMP 2 ND HRLY
5.MONITOR VITALS HRLY

SOAP NOTES Day 1

S- No fresh complaints

O- Patient is consious, coherent, co-operative.
Pallor ++ , koilonychia present
No icterus, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.6F
Pulse rate - 80 BPM, REGULAR, NORMAL VOLUME
BP - 120/80MM OF HG
SPo2 - 98% AT RA
GRBS - 99 mg/dl
SYSTEMIC EXAMINATION - 
P/A : Non distended, soft, non tender. No guarding or rigidity.Mild Splenomegaly.
CVS : S1 S2 heard , Pansystolic murmurs at Pulmonary area.
RS-BAE+
CNS- NAD
A-20 yr old female with Iron deficiency Anemia secondary to Nutritional deficiency
P-1.INJ.PANTOP 40 MG/IV/OD
2.INJ.NEOMOL 100 ML( IF TEMP >101.1F)
3.TAB.PCM 500MG/PO/SOS
4.MONITOR TEMP 2 ND HRLY
5.MONITOR VITALS HRLY

SOAP NOTES Day 2

S- No fresh complaints

O- Patient is consious, coherent, co-operative.
Pallor ++ , koilonychia present
No icterus, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.6F
Pulse rate - 84BPM, REGULAR, NORMAL VOLUME
BP - 100/60MM OF HG
SPo2 - 99% AT RA
GRBS - 99 mg/dl
SYSTEMIC EXAMINATION - 
P/A : Non distended, soft, non tender. No guarding or rigidity.Mild Splenomegaly.
CVS : S1 S2 heard , Pansystolic murmurs at Pulmonary area.
RS-BAE+
CNS- NAD
A-20 yr old female with Iron deficiency Anemia secondary to Nutritional deficiency
P-1.INJ.PANTOP 40 MG/IV/OD
2.Inj.B12  1500 Microgram IM/OD
3.TAB.PCM 500MG/PO/SOS
4.MONITOR TEMP 2 ND HRLY
5.MONITOR VITALS HRLY
6.1 PRBC TRANSFUSION DONE ON 14/4/22 

SOAP NOTES Day 3

S- No fresh complaints

O- Patient is consious, coherent, co-operative.
Pallor ++ , koilonychia present
No icterus, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.6F
Pulse rate - 84BPM, REGULAR, NORMAL VOLUME
BP - 11//70MM OF HG
SPo2 - 99% AT RA
SYSTEMIC EXAMINATION - 
P/A : Non distended, soft, non tender. No guarding or rigidity.Mild Splenomegaly.
CVS : S1 S2 heard , Pansystolic murmurs at Pulmonary area.
RS-BAE+
CNS- NAD
A-20 yr old female with Iron deficiency Anemia secondary to Nutritional deficiency
P-1.TabPANTOP 40 MG/PO/OD
2.Inj.B12  1500 Microgram IM/OD D2 alternate buttock region
3.TAB.PCM  500MG/PO/SOS
4.MONITOR TEMP 2 ND HRLY
5.MONITOR VITALS HRLY
6.TAB.OROFER XT PO/OD 2PM

SOAP NOTES Day 4

S- No fresh complaints

O- Patient is consious, coherent, co-operative.
Pallor ++ , koilonychia present
No icterus, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.6F
Pulse rate - 92 BPM, REGULAR, NORMAL VOLUME
BP - 120//70MM OF HG
SPo2 - 99% AT RA
SYSTEMIC EXAMINATION - 
P/A : Non distended, soft, non tender. No guarding or rigidity.Mild Splenomegaly.
CVS : S1 S2 heard 
RS-BAE+
CNS- NAD
A-20 yr old female with Iron deficiency Anemia secondary to Nutritional deficiency
P-1.TabPANTOP 40 MG/PO/OD
2.Inj.B12  1500 Microgram IM/OD D2 alternate buttock region
3.TAB.PCM  500MG/PO/SOS
4.MONITOR TEMP 2 ND HRLY
5.MONITOR VITALS HRLY 
6.TAB.OROFER XT PO/OD 2PM

SOAP NOTES Day 5

S- No fresh complaints

O- Patient is consious, coherent, co-operative.
Pallor + , koilonychia present
No icterus, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.6F
Pulse rate - 92 BPM, REGULAR, NORMAL VOLUME
BP - 110//70MM OF HG
SPo2 - 99% AT RA
SYSTEMIC EXAMINATION - 
P/A : Non distended, soft, non tender. No guarding or rigidity.Mild Splenomegaly.
CVS : S1 S2 heard 
RS-BAE+
CNS- NAD
A-20 yr old female with Iron deficiency Anemia secondary to Nutritional deficiency
P-1.TabPANTOP 40 MG/PO/OD
2.Inj.B12  1500 Microgram IM/OD D2 alternate buttock region
3.TAB.PCM  500MG/PO/SOS
4.MONITOR TEMP 2 ND HRLY
5.MONITOR VITALS HRLY 
6.TAB.OROFER XT PO/OD 2PM
7.1 PRBC TRANSFUSION DONE ON 17/04/2022








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