19F iron deficiency anemia

 19 Years/Female Address            Date: 25/10/2022 04:23 PM Diagnosis IRON DEFICIENCY ANEMIA TO BLOOD LOSS (ANAL FISSURE) 

Case History and Clinical Findings C/O HEADCHE SINCE 1 WEEK C/O VOMITINGS 2 DAYS BACK C/O HEAVINESS OF CHEST SINCE 2 DAYS PT WAS APPARENTLY ASYMPTOMATIC 1MONTH BACK THEN SHE HAD 2 EPISODES OF VOMITING TREATED SYMPTOMATICALLY A/W HEADACHE NON PROJECTILE NON BILIOUS FOOD PARTICLES CONTENT MENSTRUAL HISTORY - 3 DAYS/30DAYS CLOTS - , PAIN H/O IRREGULAR MENSTRUATION CYCLES MENARCHE AT 17Y NO H/O CHEST PAIN, SHORTNESS OF BREATH ,PAIN ABDOMEN ,LOOSE STOOLS, NAUSEA+ ,VOMITING -, FEVER -, WORM INFESTATION - ,PICAH/O BLEEDING PER RECTUM 1 EPISODE - TODAY [FEW RED DROPS IN STOOL]-HEMOPTYSIS -, HEMETEMESIS - ,BLEEDING GUMS HEADACHE - UNILATERAL THROBBING TYPE NON RADIATING - NO NAUSEA , VOMITING , PHOTOPHOBIA HEAVINESS OF CHEST - NOT A/W FOOD INTAKE NOT A/W EXERTION 

NUTRITIONAL HISTORY;

MORNING - TIFFIN[IDLY , DOSA , BONDA , POORI ] AFTERNOON - SAMBAR /CURRY/CURD+RICE NO SNACKS NIGHT - CURRY/PICKLE/CURD - RICE 

NO SIMILAR COMPLAINTS IN PAST N/K/C/O DM , HTN , ASTHMA , CAD , TB , EPILEPSY , BLOOD TRANSFUSIONS-PATIENT IS NOT WILLING FOR IRON SUCROSE SO 1 UNIT PRBC TRANSFUSION GIVEN. 

Investigation USG IMPRESSION MILDLY ALTERED ECHOTEXTURE OF LIVER LOW LEVEL ECHOES IN URINARY BLADDER 

Treatment Given(Enter only Generic Name) 1] INJ ZOFER 4 GM IV /SOS 2]INJ IRON SUCROSE 200 MG IN 100 ML NS OVER 2-3 HRS 3]IRON RICH DIET 4]TAB DOLO 650 MG PO/SOS 5] SYP CREMAFFIN 30 ML /PO/H/S 6]HIGH FIBRE DIET 7]ANOBLISS OINTMENT FOR LOCAL APPLICATION 8]SITZ BATH [BETADINE] 9]PLENTY OF ORAL FLUIDS 

Advice at Discharge TAB OROFER XT 100MG PO ONCE DAILY BEFORE FOOD X 1 MONTH TAB VOMIKIND 4 MG PO SOS TAB DOLO 650 MG PO/SOS SYP CREMAFFIN 20 ML ONCE DAILY BED TIME HIGH FIBRE DIET ANOBLISS OINTMENT FOR LOCAL APPLICATION SITZ BATH [BETADINE] /TID PLENTY OF ORAL FLUIDS 

Follow Up

REVIEW AFTER 15 DAYS TO GM OPD ON TUESDAYS OR SOS 

Preventive Care AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS.

 

For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language 

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