Case Study 7

 December 04 , 2021


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A 78 year old female came to OPD for swelling and

pain


HISTORY OF PRESENT ILLNESS 


Patient was apparently asymptomatic 20 days back,

then she fell from bed during her sleep and then

started to experience pain in the back , left leg and

left arm with swelling on the left arm . She came to

Kamineni for checkup then after the tests were 

done turned out to be Anemic and from then she's

on Iron sucrose IV  . In the X Ray there is Crack in

the back and the pain is radiating , due to the pain

she's unable to sleep during night times . 


PAST HISTORY 


She had 6 vaginal deliveries and her menstrual

cycle was normal .

Known case of hypertensive from many years and

she's taking Amlogen 10mg OD daily but her blood 

pressure came to normal after admitting in the

hospital and currently for the past 1 week she's not

on the medication 

Not a known case of Diabetes 

Not a known case of Tuberculosis 


PERSONAL HISTORY 


Appetite - Reduced 

Diet - vegetarian 

Bowel and bladder movement - Regular 

Sleep - Inadequate 

No history of Alcohol consumption and smoking 


FAMILY HISTORY 


No significant family history 


ON GENERAL EXAMINATION 


Patient is conscious , coherent and cooperative 

Thin built 

No pallor , icterus and cyanosis 

Temperature - 98.6

Blood pressure - 110/70mmhg 

Pulse rate - 86

Respiratory Rate - 20

SpO2 - 97%


SYSTEMIC EXAMINATION 


CVS : 


No thrills 

S1 S2 heard 

No murmurs 


RESPIRATORY SYSTEM :


No dyspnea 

Wheezing 

Trachea is in central position 

Vesicular breath sounds heard 


PER ABDOMEN :


Scaphoid in shape 

Not tender 

No palpable mass 

No free fluid 

Bowel sounds heard 


CNS : 


No focal neurological deficits 


DIAGNOSIS 


Iron deficiency anemia 









ECG

























 
TREATMENT 


Inj Iron sucrose 200mg in 100 mL NS/IV/OD

T Ultracet PO/SOS

T Shelcal 500mg PO/OD

T Gabapentin 500mg PO/HS












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