A 76YR OLD MALE DIAGNOSED WITH IRON DEFICIENCY ANEMIA

A 76YR OLA MALE OF:

Diagnosis:
SEVERE IRON DEFICIENCY ANEMIA HEART FAILURE ( EF - 57%) ACUTE GASTROENTERITIS ( RESOLVED) SLIDING HIATUS HERNIA, GERD 

Case History and Clinical Findings :
A 77 YEAR OLD MALE PRESENTED TO THE CASUALITY AND PRESENTED WITH THE COMPLAINTS OF VOMITINGS , LOOSE STOOLS AND GENERALIZED WEAKNESS SINCE ONE DAY. THE PATIENT WAS EVALUATED CLINICALLY AND WITH APPROPRIATE INVESTIGATIONS WAS PROVISIONALLY DIAGNAOSED WITH SEVERE IRON DEFICIENCY ANEMIA WITH HEART FAILURE ( EF - 57%) HEART FAILURE ( EF - 57%)ACUTE GASTROENTERITIS ( RESOLVED),SLIDING HIATUS HERNIA, GERD. THE PT WAS STARTED ON CONSERVATIVE MANAGEMENT ( IV FLUIDS NS/RL @ 100ML/HR , INJ CEFTRIAXONE 1 GM IV/BD ( 8 AM-8 PM) INJ PAN 40MG IV/TID ( 7AM-2PM-8PM) , INJ ENESET 8MG IV/TID ( 8AM-2PM-8PM) TAB ROSUVASTATIN 20MG H/S (9 PM) TAB ECOSPRIN 75MG PO/OD (8 AM), TAB CLOPRIDOGREL 75MG PO/OD ( 2 PM) , TAB PROLOMET 25 MG PO/OD ( 8AM) TAB BISACODYL 5MG (8PM 2 TABS) INJ IRON SUCROSE 200MG IN 100ML NS IV/OD , SYP GUTCLEAX 30ML OD/HS

 GENERAL EXAMINATIONTHE PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE MODERATELY BUILT AND NOURISHED SIGNS OF PALLOR, PRESENT NO CYANOSIS, CLULBBING, EDEMA ,ICTERUS VITALS: TEMP: AFEBRILE PR: 94 BPM
RR: 18 CPM BP: 130/60 MM HG SPO2: 95% @ RA GRBS: 138 MG/DL 
SYSTEMIC EXAMINATION:
CVS: S1, S2 HEARD, NO MURMURS 
RS: BAE+, NVBS TRACHEA: CENTRAL NO DYSPNOEA AND WHEEZE NO RHONCHI ABDOMEN: NON TENDER, SOFT, OBESE, LIVER AND SPLEEN NOT PALPABLE BOWEL SOUNDS NOT HEARD 
CNS: LEVEL OF CONSCIOUSNESS: CONSCIOUS, ALERT SPEECH: NORMAL NECK STIFFNESS ABSENT KERNINGS SIGN ABSENT CRANIAL NERVES: NORMAL MOTOR SYSTEM: NORMAL SENSORY SYSTEM: NORMAL GCS: 15/15 E4V5M6 TONE: UL: NORMAL LL: NORMAL POWER: UL: 5/5 BOTH LL: 5/5 BOTH REFLEXES: RT LT B: +2 +2 T: +2 +2 S: +1 +1 K: +2 +2 A: +1 +1


Investigation :
2D ECHO
 TRIVIAL TR+, AR+, NO MR NO RWMA, NO AS/MS SCLEROTIC AV GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION+, NO PAH 

USG ABDOMEN AND PELVIS IMPRESSION 
- RT SIMPLE RENAL CORTICAL CYST, LT COMPLEX RENAL CYST, B/L GRADE 1 RPD CHANGES 

Treatment :
 AS DISCUSSED BY THE PHYSICIAN

 Advice at Discharge:
 TAB TAXIM 200 MG PO BD X 5 DAYS TAB ROSUVASTATIN 20MG PO HS (9 PM) TAB ECOSPRIN 75MG PO OD (8 AM) TAB CLOPRIDOGREL 75MG PO OD ( 2 PM) TAB PROLOMET 25 MG PO OD ( 8AM) TAB BISACODYL 5MG (8PM - 2 TABS) SYP GUTCLEAR 30ML OD HS TAB LIVOGEN PO OD X 1 MONTH


DISCHARGE SUMMARY:

Diagnosis:
SEVERE IRON DEFICIENCY ANEMIA HEART FAILURE ( EF - 57%) ACUTE GASTROENTERITIS ( RESOLVED) SLIDING HIATUS HERNIA, GERD 

Case History and Clinical Findings :
A 77 YEAR OLD MALE PRESENTED TO THE CASUALITY AND PRESENTED WITH THE COMPLAINTS OF VOMITINGS , LOOSE STOOLS AND GENERALIZED WEAKNESS SINCE ONE DAY. THE PATIENT WAS EVALUATED CLINICALLY AND WITH APPROPRIATE INVESTIGATIONS WAS PROVISIONALLY DIAGNAOSED WITH SEVERE IRON DEFICIENCY ANEMIA WITH HEART FAILURE ( EF - 57%) HEART FAILURE ( EF - 57%)ACUTE GASTROENTERITIS ( RESOLVED),SLIDING HIATUS HERNIA, GERD. THE PT WAS STARTED ON CONSERVATIVE MANAGEMENT ( IV FLUIDS NS/RL @ 100ML/HR , INJ CEFTRIAXONE 1 GM IV/BD ( 8 AM-8 PM) INJ PAN 40MG IV/TID ( 7AM-2PM-8PM) , INJ ENESET 8MG IV/TID ( 8AM-2PM-8PM) TAB ROSUVASTATIN 20MG H/S (9 PM) TAB ECOSPRIN 75MG PO/OD (8 AM), TAB CLOPRIDOGREL 75MG PO/OD ( 2 PM) , TAB PROLOMET 25 MG PO/OD ( 8AM) TAB BISACODYL 5MG (8PM 2 TABS) INJ IRON SUCROSE 200MG IN 100ML NS IV/OD , SYP GUTCLEAX 30ML OD/HS GENERAL EXAMINATIONTHE PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE MODERATELY BUILT AND NOURISHED SIGNS OF PALLOR, PRESENT NO CYANOSIS, CLULBBING, EDEMA ,ICTERUS VITALS: TEMP: AFEBRILE PR: 94 BPM
RR: 18 CPM BP: 130/60 MM HG SPO2: 95% @ RA GRBS: 138 MG/DL CVS: S1, S2 HEARD, NO MURMURS RS: BAE+, NVBS TRACHEA: CENTRAL NO DYSPNOEA AND WHEEZE NO RHONCHI ABDOMEN: NON TENDER, SOFT, OBESE, LIVER AND SPLEEN NOT PALPABLE BOWEL SOUNDS NOT HEARD CNS: LEVEL OF CONSCIOUSNESS: CONSCIOUS, ALERT SPEECH: NORMAL NECK STIFFNESS ABSENT KERNINGS SIGN ABSENT CRANIAL NERVES: NORMAL MOTOR SYSTEM: NORMAL SENSORY SYSTEM: NORMAL GCS: 15/15 E4V5M6 TONE: UL: NORMAL LL: NORMAL POWER: UL: 5/5 BOTH LL: 5/5 BOTH REFLEXES: RT LT B: +2 +2 T: +2 +2 S: +1 +1 K: +2 +2 A: +1 +1
Investigation 2D ECHO TRIVIAL TR+, AR+, NO MR NO RWMA, NO AS/MS SCLEROTIC AV GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION+, NO PAH USG ABDOMEN AND PELVIS IMPRESSION - RT SIMPLE RENAL CORTICAL CYST, LT COMPLEX RENAL CYST, B/L GRADE 1 RPD CHANGES Treatment Given(Enter only Generic Name) AS DISCUSSED BY THE PHYSICIAN Advice at Discharge TAB TAXIM 200 MG PO BD X 5 DAYS TAB ROSUVASTATIN 20MG PO HS (9 PM) TAB ECOSPRIN 75MG PO OD (8 AM) TAB CLOPRIDOGREL 75MG PO OD ( 2 PM) TAB PROLOMET 25 MG PO OD ( 8AM) TAB BISACODYL 5MG (8PM - 2 TABS) SYP GUTCLEAR 30ML OD HS TAB LIVOGEN PO OD X 1 MONTH

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