MAJOR CASE PRESENTATION ON

SEVERE ANEMIA
• 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.
• LABORATORY INVESTIGATIONS:
test Patient value Normal value
RBC 1.38 million/μl 4.5-6.2 million/μl
WBC 2690 cumm 4000-11000 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 <40
Sr.Bilirubin conjugated 1.0 0.1-1.2mg/dl
Unconjugated 1.0 0.2-0.7mg/dl

• Peripheral smear: Macrocytic anemia

• 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.
• 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.
• 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.
• PLAN OF CARE:
• GOALS OF THERAPY:
• To alleviate signs and symptoms
• Correcting the underlying etiology
• Prevent reoccurence of anemia.
S.n Brand name Generic name Dose & Day
o freuency 1 2 3 4 5
1. Inj.Vomikind iv ondansetron 1-1-1 Y Y Y Y
20mg
2. Inj.Pantodac pantoprazole 40mg Y Y Y Tb Y
1-0-0 Y
3. Tb. Anxit alprazolam 0.5mg Y Y Y Y Y
0-0-1
4. Cp.Omegapace 0-1-0 Y Y Y Y Y
5. Inj.Orofer S Iron sucrose In 100ml Y Y Y Y Y
NS 1-0-1
6. Inj.Vitcofol im Folic acid ,multi 2cc Y Y Y Y Y
vit,Ferrous 0-1-0
sulphate
7. Inj.Divon im Diclofenac Na s-o-s Y Y Y
8. Syp.orofer Xt Elemental iron 1-1-1 Y Y Y
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 1-0-1 x 15 days
2. syp. Fesovit 0-1-1 x 15 days
3. Tab. Anxit 0.5mg 0-0-1 x5 days
4. cap. Omegapace 0-1-0
THANKING YOU