Case Presentation

on
Iron Deficiency Anemia

Reg No. 14Q1001

Patient details:
• Age : 60 years

• Wt :68kg

• Sex: male

• Date of admission: 13/09/18

• Date of discharge: 16/09/18

• Unit : Medicine D
Complaints on admission

• C/o Generalized weakness since 3 weeks

• c/o itching since 4 days

• Past medication History: Nothing significant
• Social history :- diet:mixed, appetite:good
• Bowel and Bladder: Regular
• Family history :- nothing significant.
SOAP ANALYSIS
Subjective evidence:
• C/o Generalised weakness since 3 weeks.

• C/o itching since 4 days

Objective evidence:
• Hb – 4.5G%

• PCV-16.6%(37-46%)

• MCV- 70.6fl(80-96fl)

• MCH-19.1pg(27-33pg/cells)

• Peripheral blood smear: Microcytic,

hypochromic red blood cells
Assessment

From the subjective and objective evidence it is diagnosed

as the patient is suffering from Iron Deficiency Anemia.
Therapeutic goals

Patient specific
To relieve from generalized weakness and itching
Disease specific
To increase hemoglobin and other counts in blood.
 Assessment of current therapy
Drug Brand name Dose Rout Frequ- 1 2 3 4
e ency

Tab. Albendazole Albendol 400 mg po 0-0-1 +

cap. Haem – up Haem up po 1-0-1 + + + +

Cap. Multivitamin Neurobion-forte po 0-1-0 + + + +

B protein Powder 2 table po 2-0-2 +

spoon

Tab.Ranitidine Rantac 150 mg po 1-0-0 + + + +

Progress chart
Day of admission Generalised weakness
PR 80 bpm
BP 118/80 mm Hg

Day 2 PR 78 bpm
BP 110/80 mm Hg

Day 3
PR 80 bpm
BP 110/80 mm Hg
Hb – 6.5 g%

Day 4 Patient is comfortable.

PR 80 bpm
BP 118/80 mm Hg
Planning :
Discharge Medications:
• Cap. Heamup 1-0-1 30 days
• B Protein Powder (2 table spoon) 0-1-0 for 10 days
• T. Ranitidine 150 mg 1-0-1 30 days
 Monitoring Parameters

• Albendazole:Headache,hepatotoxicity, neutropenia, abdominal

pain, dry mouth.
Pantoprazole:Abdomenal pain, headache, constipation, back
pain, cough, rash.
Haem up:Constipation, diarrhoea, epigastric pain, nausea,
vomiting, temporarily discolored tooth enamel and eyes.
 Patient counseling(drug specific)

• Albendazole: Serum level increases 4 – folds with fatty meal. So

tell patient to take with fatty meal.
• Ranitidine: Tell patient to take 30 minutes before food.
• Iron preparations:Best absorbed on empty stomach. But if GI
upset occurs take with food. Tell the patient that iron changes
stools black or dark green. Cereals, cheese, coffee, eggs, milk,
tea, bread may impair oral iron absorption. So should not be
taken together.
 Patient Counselling (Disease specific):
• Take the food containing iron (green leafy vegetables, beef liver,
spinach, beans, dates, potato etc.)
•Get adequate protien from soya bean plant food combination such
as beans or lentils .
•Exercise stimulates the bone marrow to produce blood cells
• Fresh air is essential for cleansing the blood.
•Fruits and vegetables are good source of anti oxidants which
counteract harmful free radical activity.
Thank you