anemia presentation.pptx .

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1. Anemia Presentation

2. Name: D.K Sex: Female Age: 21 years Address: Makeni Villa Religion: Christian Martial Status: Single Occupation: Currently not working Self referral Informant: D.K Language: English

3. CHIEF COMPLAINS Generalised body weakness 2/7 Headache 2/7 Joint pain 3/7

4. History of Presenting Complains Patient was on her usual state of health till two days prior to admission when she started having generalised body weakness She would feel extremely tired even at rest This was associated with a non-radiating frontal headache which she rated 7/10 in severity She used to take paracetamol to relieve the pain She admits having palpitations and dizziness 2 days before admission However she denies any history of difficulty in breathing, difficulty in breathing when lying flat and chest pain There was no history of fainting episode, convulsions and blury vision.

5. Patient also complained of sudden joint pain which was sharp in nature and non-radiating. The pain was rated 8/10 on severity and was relieved by paracetamol However, there was no history of trauma , swelling,joint stiffness as well as skin rash. The patient had similar presentation in 2022 when she was told that she had low blood levels.

6. Review of systems G.I.T - no diarrhea -no constipation -appetite loss 3/7 -no hx of vomiting -no abdominal pain -no jaundice R.S -no cough -no chest pain

7. GUT - normal urine frequency ~no painful urination ~no change in stool colour

8. Menstrual History LNMP was 13/02/25 It lasted for for 6 days using each pad in a day which was not fully soaked However, on the day of clerkship, patient had started her menses again after 6 days from her last period. This period was associated with abdominal discomfort and had used 2 pads in that particular day which were not soaked. There is history of heavy menstrual bleeding in 2022 ,with usage of 4 fully soaked diapers in a day. This was resolved by 3 months hormonal therapy on microgynon. Patient has never been pregnant before and her menarche at 12 years. She is not on any other family planning method but is sexually active. She has never had a cervical cancer screening before

9. Drug History D.K used to take microgynon She received two units of blood in 2022 due to similar presentation She used herbs at home(unknown name) to increase her blood levels No history of use of any other pain relief drugs except for paracetamol. No known drug allergies

10. Medical History No history of Diabetes, Epilepsy, Asthma, Tuberculosis, Hypertension and Sickle Cell disease She is RVD-NR (verbally)

11. Family History No history of Epilepsy,Sickle Cell disease,Asthma and Tuberculosis in the family Her grandfather is diabetic and her grandmother is hypertensive

12. Social History She denies consumption of alcohol and smoking She resides in a 5 roomed house with 4 occupants She's not a vegetarian,she eat meat at least three times in a week They use tap water and borehole water They use a pit latrine There's no similar presentation with her siblings.

13. Summary Presenting D.K ,F (21) ,self-referral who came in with complains of fatigue 2/7, non-radiating headache2/7 ,joint pain 2/7 ,palpitations, dizziness and a positive history of menorrhagia. However she denies having orthopnea,PND and dysnoea. J

14. First impression Severe anemia secondary to; Menorrhagia Iron deficiency anemia

15. Differentials Sickle Cell disease Malaria Abortion •Cervical cancer Fibroids

16. PHYSICAL EXAMINATION

17. Vitals Vitals Date of Admission Date of clerking Blood Pressure 128/70 mmHg 107/77mmHg Pulse 174bpm 67bpm Respiratory Rate 21bpm 20bpm Temperature 37.4°C 37.1°C

18. General Examination • Consent was requested and granted •From the footend of the bed, a young female of good nutritional status was observed. She was alert and well oriented •She was lying supine, and was not in obvious respiratory distress •She had a cannular on left hand and was actively receiving medication

19. From the right side of the bed HANDS •No finger clubbing, no splinter hemorrhage, no koilonychia, no leukonychia, no Dupuytrens's contracture. •No palmar pallor,no palmar erythema, no nicotine stains, no cyanosis •Cold finger extremities, CRT >3 seconds •Pulse was regular, voluminous, non bounding and there was Radio-radial synchronity

20. HEAD AND FACE •Good black hair distribution •No scleral jaundice •Conjuctival pallor present •Moist membranes •No cheilitis •No glossitis •Good dental hygiene •No lymphadenopathy

21. CHEST ON INSPECTION • Normal overlying skin, no tattoos or scars. Chest is symmetrical and has no deformities ON PALPATION • Apex beat found on the 5th intercoastal space, mid clavicular line. ON PERCUSSION •Resonant sounds heard on percussion ON AUSCULTATION CVS- S1 and S2 heard, no additional heart sounds RS- Bilateral air entry. Vessicular breath sounds

22. ABDOMEN •Normal overlying skin, no scars or tattoos •Abdomen moves with respiration •Soft and non tender •No distension •No palpable masses •Normal bowel sounds

23. MUSCULOSKELETAL SYSTEM •Muscle bulk is normal and there appears to be no wasting • Normal muscle tone •Muscle power is 5/5 on all limbs •No rash or sores •No pedal edema

24. Consent was denied to conduct vaginal examination as well as digital rectal examination.

25. Summary Presenting a young female of average weight, who was conscious and had positive findings of mild pallor and cold finger extremities. Negative findings for any organomegaly , palpable masses or pedal edema.

26. Impression Severe anaemia secondary to •Menorrhagia •Iron Deficiency

27. Differential diagnosis •Folate deficiency • Vitamin B-12 deficiency • Malaria •Sickle Cell Disease

28. Investigations 1. FBC 2. RDT and MPS 3. Stool m/c/s 4. Sickling Test 5. Peripheral smear

29. • Low RBC count •Low HGB •Low HCT •Low MCV •Low MCH •Low MCHC •High RDW

30. Proposed Investigations LABS Full Blood count -To check for Hb levels and grade the severity of anemia - to confirm the type of anemia - to check presence of any other infection Iron Studies -To check for ferritin levels and folate as well as serum cobalamin

31. •Blood fil m - to check for abnormally shaped RBCs •Reticulocyte count - check for compensatory erythropoiesis • Clotting time - ( to check for coagulopathy -von Willebrand disease) • DCT •Hb Electrophoresis •Sickling Test •Abdominal ultrasound •°Gravindex

32. Management Patient was on •Iron sucrose 100mg IV •Folic acid 5mg OD PO •Ferrous Sulphate 200mg PO TDS