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Age: 26 years
Weight: 46 kg
Gender: Male Date of admission:15/09/10
Date of discharge: 24/09/10
Days spent in Hospital: 10 Days
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C/O
Breathlessness X 15 days
Weakness X 10 days
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Patient History: Breathlessness on Walking little distance, where
the patient has to take rest and move on further. Yellowish Discolorisation of Urine & Eye X 1
month back
H/O Nausea & Vomiting
Appetite Palpitation Fatigue Generalized Weakness
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Smoking Cigarette 20 sticks/week X 3 yr Chewing Gutka 5 Packets/day X 10 yr
Pt. has taken local treatment for yellowdiscolorisation of eye & urine which subsidesafter 20 days. But appetite persisted
When symptoms of breathless & Fatigue ed
,local Dr. done blood investigation on 10/09/10Hb was 3.4 gm%
Pt. had developed rashes to all over body 3month back
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Dates
Parameters
16/09/10 18/09/10 20/09/10 23/09/10
Hb
(11.5-18 gm%)
3.1 8.6 9.2 9.8
Lymphocytes(20-40)
44 - - -
Vit.B12(208-964pg/ml)
193 - - -
RBC (4.5-6.5million/cmm) 2.46
PCV(40-50%) 23 - - -
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Blood Transfusion :
Inj.Frusemide 20 mg given
Date Started at Stopped at
15/09/10 11.55 am 02.10 am
16/09/10 06.35 pm 09.15 pm
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MegaloblasticAnaemia
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THERAPEUTICGOALS:
To Relieve signs and symptoms
To normalize hemoglobin level
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MEDICATION (NAME,STREGNTH,ROUTE,DOSE)
DATESTARTED
DATESTOPPED
INDICATION
IV fluid 75ml/hr 15/9/10 19/9/10 Nutritional supplement
Tab.MV/BC1-0-0
15/9/10 24/9/10 multivitaminsupplement
Tab. Ranitidine 150mg1-0-1
15/9/10 24/9/10 Gastritis
Tab. Folic acid 5mg0-1-0
18/9/10 DM Nutritional supplement
Tab.Ferrous ascorbate 100mg0-1-0
18/9/10 DM Haematopoietic
Inj.nicotinamide
200mg,vit.B12 500mcg,Folicacid 15mgper ml 2cc
18/9/10 DM Nutritional supplement
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MEDICATION (NAME,STREGNTH,ROUTE,DOSE)
DATESTARTED
DATESTOPPED
INDICATION
Power. Isapghula Husk3.5 mg ,2tsp with water0-0-1
21/9/10 DM Laxative
Oint.Lidocaine HCL21.3 mg
21/9/10 24/9/10 Skin Rashes
Tab.Serrapeptase 5mg
1-0-1
21/9/10 24/9/10 Inflammation
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THERAPEUTICMONITORING:
Patient is symptomatically improved
TOXICITY MONITORING
Nausea, Abdominal pain, Diarrhea may becaused due to Ferrous Ascorbate. So it has to bemonitored.
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Discharge Medication:
Tab. Folic acid 5mg 0-1-0
Inj.nicotinamide 200mg,vit.B12 500mcg,Folic acid
15mgper ml 2cci.m twice weekly X 1 month
then once a month
Tab. Ferrous ascorbate 100 mg 1-0-1
Power. Isapghula Husk 3.5 mg ,2tsp with water 0-0-1
Follow up after 1 month
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Disease
Drugs
Life style modification
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