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Major Case Anemia On
Major Case Anemia On
Major Case Anemia On
SEVERE ANEMIA
• SCENARIO:
Here is a 60 years old male patient admitted in medicine male ward
diagnosed as Severe anemia was hospitalised for 5
days.
CHIEF COMPLAINTS:
c/o weakness since 1month
c/o loss of appetite since 1 month
Bone marrow aspiration done twice but the needle was blocked with
fat unable to aspirate the marrow.
SOAP NOTE:
Subjective:
Here is a 60years old male presenting complaints of weakness and
Loss of appetite since 1 month.
• Objective:
• RBC is decreased that indicates anemia.
• WBC is decreased which implies diminished bone marrow
function
• Platelet count is reduced due to diminished bone marrow function
• Hb is drastically decreased which indicates severe anemia
• ESR is increased due to infection
• PCV is decreased that indicates over hydration or due to anemia.
• MCV & MCH values are increased which indicates macrocytic
hyperchromia.
• SGOT & SGPT levels are increased that indicates liver damage
• Sr bilirubin values are increased that indicates there may be a
liver damage
• Peripheral smear shows macrocytic anemia.
• Diagnosis: By observing the above subjective and objective data
the patient is diagnosed with severe anemia.
ASSESSMENT:
Problem list:
1.Weakness
2.Loss of appetite
3.Severe anemia
Patient counselling:
Patient is adviced to take iron rich diet such as green leafy
vegetables, fruits, egg, liver, kidney etc,
Discharge drugs:
1.Cap.Vitcofol 1-0-1 x 15 days
2. syp. Fesovit 0-1-1 x 15 days
3. Tab. Anxit 0.5mg 0-0-1 x5 days
4. cap. Omegapace 0-1-0
THANKING YOU