A.

PERSONAL PROFILE

Name : MC. Manuel

Age : 26

Address : Careb, Bagabag, Nueva Vizcaya

Civil Status : Single

Name of Spouse : N/A

Occupation : Student / Call Center Agent ( Virtual Assistant )

Educational Attainment : College Level

Chief Complaint : Body weakness

Admission Diagnosis : Anaphylactic Reaction 2° lactogenic cause ( IV Iron ) IDA

Date of Admission : April 6, 2024 ; 9: 09 Pm

Attending Physician : Dr. Richard Lopez

Principal Diagnosis : Anaphylactic Reaction 2° lactogenic cause ( IV Iron ) IDA

Date of Discharge :

B. HISTORY OF PRESENT ILLNESS

One day prior to admission Ms. M went to Region 2 Trauma Medical Centre fir her laboratory tests
because she was complaining of her dizziness and body weakness the tests came out normal, and
her situation was managed and she went home. The following day April 6, 2024 she once again went
to Region 2 Trauma medical Centre for her iron infusion but wasn’t able to administer it due to
higher demand of other clients, wherein at that time she was already complaining of her body
weakness. So, she decided to transfer at PLT Medical Center where she was currently admitted ,
according to Ms. M she was suffering from iron deficiency but can not take iron supplements for she
is allergic to it, every time she intakes iron she suffers from difficulty of breathing, and this was
recurring from almost a year now. The iron infusion also lead to occurrence of her anaphylactic shock

C. History of Past Illness

According to Ms. M she was diagnosed with iron deficiency or anemia and was prescribed to
undergo iron infusion, she also had episodes body weakness. Ms. M was admitted last May 2024 due
to her disease , she was also rushed to E.R last November and stayed there for a day and last January
she experienced seizure. Additionally on their family health history her older sister was also
experiencing the same disease , but neither of her parents suffers from it. Ms. M states that may be
some other factor of her disease was from her work and study, since she was a working student and
barely sleeps at night due to the nature of her work as an virtual assistant, and during the day she
was a chemical engineering student at Adamson University, she undergone iron infusion monthly at
Region 2 Trauma Medical center other than this she doesn’t take any cultural or herbal medicines.
II. BRIEF DESCRIPTION OR BACKROUND OF THE PATIENT’S ILLNESS

Iron deficiency anemia is a common type of anemia — a condition in which blood

lacks adequate healthy red blood cells. Red blood cells carry oxygen to the body's
tissues. As the name implies, iron deficiency anemia is due to insufficient iron.
Without enough iron, your body can't produce enough of a substance in red blood
cells that enables them to carry oxygen (hemoglobin). As a result, iron deficiency
anemia may leave you tired and short of breath.You can usually correct iron
deficiency anemia with iron supplementation. Sometimes additional tests or
treatments for iron deficiency anemia are necessary, especially if your doctor
suspects that you're bleeding internally.

Initially, iron deficiency anemia can be so mild that it goes unnoticed. But as the body
becomes more deficient in iron and anemia worsens, the signs and symptoms
intensify.Iron deficiency anemia signs and symptoms may include:

Extreme fatigue, Weakness, Pale skin, Chest pain, fast heartbeat or shortness of
breath, Headache, dizziness or light-headedness, Cold hands and feet, Inflammation
or soreness of your tongue, Brittle nails, Unusual cravings for non-nutritive
substances, such as ice, dirt or starch, Poor appetite, especially in infants and
children with iron deficiency anemia.