際際滷

際際滷Share a Scribd company logo

case on anaemia

Download as PPTX, PDF
M
maheshwari14

This document presents a case study of a 6-year-old boy admitted to the hospital with fever for 4 days, cough and cold for 1 week, and decreased urine output. Examination found the boy to be conscious but with low blood pressure and oxygen saturation. Laboratory tests revealed microcytic hypochromic anemia, bronchopneumonia, and urine culture growing Klebsiella. He was diagnosed with anemia, bronchopneumonia, and fever and treated with oxygen, IV fluids, antibiotics, paracetamol, zinc, and iron/folic acid supplements. Diet and medication counselling was provided upon discharge.

1 of 21
Download to read offline
PHARMACOTHERAPEUTICS- III SUBMITTED BY: MAHESHWARI IV PHARM D
CASE STUDY ON ANAEMIA
SUBJECTIVE A 06 year old male boy was admitted on PMCH Erode on 06-12-2018 , with complaints of fever for past 4 days.
HISTORY OF PRESENT ILLNESS: H/O fever for past 4 days intermittent grade not associated with chills and rigors. H/O cough and cold 1week, yellow, not blood stained, no foul smell. H/O decreased urine output H/O cry during micturation. H/O loose stools before 1 week H/O recurrent respiratory infection (+)
PAST HISTORY: H/O nebulisation (+) H/O hospitalisation at 3 yrs of age. FAMILY HISTORY: H/O TB for his grand father completed treatment before 4 years.
GENERAL EXAMINATION conscious ,oriented BP : 86/58 mmHg PR : 60bpm Spo2: 87% without O2 and 100% with O2. Temp: 99.9 F
SYSTEMIC EXAMINATION CVS - S1S2 Heard RS - BAE+ ( wheeze) CNS - NFND P/A - Soft not tender
OBJECTIVE INVESTIGATION CHART NAME OF INVESTIGATION OBSERVED VALUE NORMAL VALUE WBC 8.9x109/L 4.5-10.5109/L RBC 3.86x1012/L 3.8-5.91012/L HAEMOGLOBIN 7.1g/dl 13.5-17.5g/dl PLATELETS 275.0109/L 130-400109/L MCV 58.9 FL 80-100FL HCT 33.2% 35-50% MCH 18.6pg 27- 34pg MCHC 31.4g/dl 33-36g/dl
BIOCHEMISTRY BLOOD UREA 17 mg/dl 10-40 mg/dl S. CREATININE 0.7mg/dl 0.5-1.2mg/dl URINE ANALYSIS COLOUR Pale yellow REACTION Acidic ALBUMIN +
OTHER TEST: CXR : Bronchopneumonia 7/12/2018 BLOOD CULTURE: Methicillin resistant staphylococcus Amikacin Linezolid sensitive URINE CULTURE Klebsilla : 105 CFU/ml [ significant bacteria] Amikacin nitrofurantoin Gentamycin cefeperazone sensitive Piperacillin
ASSESMENT FINAL DIAGNOSIS Anaemia [ microcytic hypochromic anaemia] Bronchopneumonia Fever for evaluation
DRUG CHART GENERIC NAME DOSE ROA FRQ DATE 06 07 08 09 10 11 Nasal O2 IVF Dextrose Normal Saline 84ml/hr IV BD Inj. Dexamethasone 450mg IV BD C. Oseltamivir 15mg Oral 1-0-1 Syp. Zinc Sulfate 20mg Oral 5ml- 5ml- 5ml Syp.Paracetamol 125mg Oral TDS T.Ferrous fumarate+ folic acid 50mg Oral BD VITAL MONITORING
DISCHARGE SUMMARY The patient was discharged on 13/12/18. DISCHARGE ADVICE Syp. Zinc oral 5ml-5ml-5ml Syp.Paracetamol 125mg SOS T.Ferrous Fumarate + Folic Acid 50mg TDS C.Oseltamivir 15mg Oral BD
PLAN
DIET BASED COUNSELLING Vitamin C sources like guavas ,berries oranges etc should be taken as it maintains healthy blood vessels and it increases absorption of iron. Vitamin E sources such as cabbage , soybeans ,sprouts, carrots etc should be taken. Consume iron rich organ meats like heart , kidney of lamb and beef tongue.
Foods high in calcium should not be eaten at the same time as iron rich foods. Milk should be avoided as it is not a good source of iron, in fact milk makes it harder for the body to absorb iron.
BRONCHOPNEUMONIA : Take a diet of protein rich foods like eggs, seafoods as it repairs the damaged tissue. Drink more water to flush out waste products and moisten the tissues.
DISEASE BASED COUNSELLING Identification for the type of anaemia is important for the treatment. Extend of the disease proceeded and appropriate co-morbidities should be explained to the patient. Sanitation is very important for the patient with the respiratory tract infection because it may lead to further infection
DRUG BASED COUNSELLING: T.PARACETAMOL: Should be adminstered twice a day. Do not exceed the prescribed dose. T.FERROUS FUMERATE: Advised the patient to take this tablet along with citrus fruit juices to enhance absorption of iron. C.OSELTAMIVIR: Take this medication with food or milk to minimize stomach upset.
SYRUP.ZINC : It should be taken as whole as its taste bitter. And it should be taken in a measuring cup as told by the doctor.
THANK YOU

More Related Content

case on anaemia

  • 3. SUBJECTIVE A 06 year old male boy was admitted on PMCH Erode on 06-12-2018 , with complaints of fever for past 4 days.
  • 4. HISTORY OF PRESENT ILLNESS: H/O fever for past 4 days intermittent grade not associated with chills and rigors. H/O cough and cold 1week, yellow, not blood stained, no foul smell. H/O decreased urine output H/O cry during micturation. H/O loose stools before 1 week H/O recurrent respiratory infection (+)
  • 5. PAST HISTORY: H/O nebulisation (+) H/O hospitalisation at 3 yrs of age. FAMILY HISTORY: H/O TB for his grand father completed treatment before 4 years.
  • 6. GENERAL EXAMINATION conscious ,oriented BP : 86/58 mmHg PR : 60bpm Spo2: 87% without O2 and 100% with O2. Temp: 99.9 F
  • 7. SYSTEMIC EXAMINATION CVS - S1S2 Heard RS - BAE+ ( wheeze) CNS - NFND P/A - Soft not tender
  • 8. OBJECTIVE INVESTIGATION CHART NAME OF INVESTIGATION OBSERVED VALUE NORMAL VALUE WBC 8.9x109/L 4.5-10.5109/L RBC 3.86x1012/L 3.8-5.91012/L HAEMOGLOBIN 7.1g/dl 13.5-17.5g/dl PLATELETS 275.0109/L 130-400109/L MCV 58.9 FL 80-100FL HCT 33.2% 35-50% MCH 18.6pg 27- 34pg MCHC 31.4g/dl 33-36g/dl
  • 9. BIOCHEMISTRY BLOOD UREA 17 mg/dl 10-40 mg/dl S. CREATININE 0.7mg/dl 0.5-1.2mg/dl URINE ANALYSIS COLOUR Pale yellow REACTION Acidic ALBUMIN +
  • 10. OTHER TEST: CXR : Bronchopneumonia 7/12/2018 BLOOD CULTURE: Methicillin resistant staphylococcus Amikacin Linezolid sensitive URINE CULTURE Klebsilla : 105 CFU/ml [ significant bacteria] Amikacin nitrofurantoin Gentamycin cefeperazone sensitive Piperacillin
  • 11. ASSESMENT FINAL DIAGNOSIS Anaemia [ microcytic hypochromic anaemia] Bronchopneumonia Fever for evaluation
  • 12. DRUG CHART GENERIC NAME DOSE ROA FRQ DATE 06 07 08 09 10 11 Nasal O2 IVF Dextrose Normal Saline 84ml/hr IV BD Inj. Dexamethasone 450mg IV BD C. Oseltamivir 15mg Oral 1-0-1 Syp. Zinc Sulfate 20mg Oral 5ml- 5ml- 5ml Syp.Paracetamol 125mg Oral TDS T.Ferrous fumarate+ folic acid 50mg Oral BD VITAL MONITORING
  • 13. DISCHARGE SUMMARY The patient was discharged on 13/12/18. DISCHARGE ADVICE Syp. Zinc oral 5ml-5ml-5ml Syp.Paracetamol 125mg SOS T.Ferrous Fumarate + Folic Acid 50mg TDS C.Oseltamivir 15mg Oral BD
  • 14. PLAN
  • 15. DIET BASED COUNSELLING Vitamin C sources like guavas ,berries oranges etc should be taken as it maintains healthy blood vessels and it increases absorption of iron. Vitamin E sources such as cabbage , soybeans ,sprouts, carrots etc should be taken. Consume iron rich organ meats like heart , kidney of lamb and beef tongue.
  • 16. Foods high in calcium should not be eaten at the same time as iron rich foods. Milk should be avoided as it is not a good source of iron, in fact milk makes it harder for the body to absorb iron.
  • 17. BRONCHOPNEUMONIA : Take a diet of protein rich foods like eggs, seafoods as it repairs the damaged tissue. Drink more water to flush out waste products and moisten the tissues.
  • 18. DISEASE BASED COUNSELLING Identification for the type of anaemia is important for the treatment. Extend of the disease proceeded and appropriate co-morbidities should be explained to the patient. Sanitation is very important for the patient with the respiratory tract infection because it may lead to further infection
  • 19. DRUG BASED COUNSELLING: T.PARACETAMOL: Should be adminstered twice a day. Do not exceed the prescribed dose. T.FERROUS FUMERATE: Advised the patient to take this tablet along with citrus fruit juices to enhance absorption of iron. C.OSELTAMIVIR: Take this medication with food or milk to minimize stomach upset.
  • 20. SYRUP.ZINC : It should be taken as whole as its taste bitter. And it should be taken in a measuring cup as told by the doctor.

Editor's Notes