ANEMIA CASE SCENARIO

NAEEM SHERASIA
ROLL NO. 42
AIIMS RAJKOT
 SOCIODEMOGRAPHIC DETAILS

MY ANTENATAL CASE IS UNBOOKED CASE OF 23 YRS OLD HINDU FEMALE PATIENT

NAMED MRS. ABC RESIDENT OF MADHAPAR, RAJKOT, UNEDUCATED,LABOURER BY
OCCUPATION MARRIED TO MR. XYZ FROM 2 YEARS BELONGING LOWER
SOCIOECONOMIC CLASS AS PER MODIFIED KUPPUSWAMY SCALE PRESENTED TO
THE OBSTETRICS OPD AT AIIMS RAJKOT ON 12/2/2024 AT 10 AM WITH CHEIF
COMPLAINTS OF
• AMENORRHEA FROM 6 MONTHS
• FATIGUE FROM 1 MONTH
• BREATHLESSNESS ON EXERTION FROM 15 DAYS
 HISTORY OF PRESENT ILLNESS

THE PATIENT WAS IN HER USUAL STATE OF HEALTH 30 DAYS BACK AFTER WHICH
SHE STARTED TO FEEL TIRED WHICH INCREASED IN INTENSITY AND DURATION
SUCH THAT SHE IS UNABLE TO DO HIS DAILY OCCUPATION. HER FATIGUE IS
ASSOCIATED WITH BREATHLESSLESSNES WHICH INCREASES ON EXERTION WHICH
REDUCES ON REST. THE BREATHLESSNESS IS NOT ASSOCIATED WITH GIDDINESS,
PALPITATION, COUGH, NIGHT SWEATS, WEIGHT LOSS, BLEEDING OR LEAKING PER
VAGINUM, BLEEDING PER RECTUM,HEMATURIA, FEVER AND YELLOWISH
DISCOLORATION OF SKIN AND SCLERA.
 HISTORY OF PRESENT PREGNANCY

1ST TRIMESTER:
SHE CONCIEVED SPONTANEOUSLY AND HER PREGNANCY WAS DETECTED BY
URINE PREGNANCY TEST AT HOME WHEN SHE MISSED HER PERIODS. SHE HAS NOT
TAKEN FOLIC ACID TABLETS AND NOT DONE HER 1ST USG SCAN. SHE HAD MILD
NAUSEA AND VOMITING(2-3 TIMES /DAY) AND NO COMPLAINTS OF FEVER,
ABDOMINAL PAIN, BURNING MICTURITION, BLEEDING PER VAGINUM.
 MENSTRUAL HISTORY

• AGE OF MENARCHE: 13 YEARS

• SHE HAD REGULAR MENSTRUAL CYCLE EVERY 30 DAYS AND HER MENSES LAST
FOR 5 DAYS WHICH ARE NORMAL(1 CLOTH/DAY) IN AMOUNT
• LMP: 6/8/2023(POG: 27 WKS 1 DAY)
• EDD: 13/5/2024
 OBSTETRIC HISTORY

• G2P1A0L1
• HER 1ST PREGNANCY WAS 2 YEARS BACK WHICH WAS A MALE CHILD DELIVERED
AT 9 MONTHS BY VAGINAL DELIVERY AND NOT ASSOCIATED WITH ANY
COMPLICATIONS. THE MALE CHILD IS 2 YEARS OLD, BIRTH WT. 1.9 KG,
VACCINATED UP TILL DATE
 PAST HISTORY

• NO HISTORY OF DIABETES, HYPERTENSION, TUBERCULOSIS OR THYROID

DISORDER.
• NO SIGNIFICANT PAST SURGICAL HISTORY
• NO HISTORY OF PRIOR BLOOD TRANSFUSION
 CONTRACEPTIVE HISTORY

• SHE HAS NOT USED ANY CONTRACEPTIVES TILL DATE.

 PERSONAL HISTORY

• SHE IS VEGETARIAN BY DIET AND TAKES INADEQUATE DIET(1645 KCAL) AS PER

HIS SEX AND OCCUPATION
• SHE HAS NORMAL BOWEL AND BLADDER MOVEMENTS
• SHE TAKES 8 HRS OF SLEEP
• SHE IS NOT ADDICTED TO TOBBACO, ALCOHOL OR ANY OTHER DRUG
• HER MARRIAGE IS NON CONSANGUINEOUS
• BLOOD GROUP : B+VE
 GENERAL EXAMINATION

• BUILD: THIN
• WEIGHT: 42 KG
• HT: 148 CM
• PALLOR: PRESENT
• ICTERUS , CLUBBING, CYANOSIS, OEDEMA AND LYMPHADENOPATHY ARE ABSENT
 VITALS

• PULSE RATE: 95/MIN

• RESPIRATORY RATE: 16/MIN
• BLOOD PRESSURE: 116/74 MMHG
• SPO2: 98%
 SYSTEMIC EXAMINATION

• RESPIRATORY SYSTEM : BILATERAL VESICULAR BREATH SOUNDS HEARD AND NO

ABNORMALITY DETECTED ON INSPECTION, PALPATION AND PERCUSSION
• CARDIOVASCULAR SYSTEM: BOTH S1 AND S2 HEARD. ABSENCE OF MURMUR OR
ANY ADDED HEART SOUNDS. REST NO ABNORMALITY DETECTED ON
INSPECTION, PALAPTION
• CENTRAL NERVOUS SYSTEM: ORIENTED TO TIME, PLACE AND PERSON. NORMAL
SENSORY, MOTOR AND CRANIAL NERVE EXAMINATION
 OBSTETRIC EXAMINATION
• INSPECTION:
THE ABDOMEN WAS DISTENDED AND UMBILICUS WAS EVERTED. THERE WERE
STRIA GRAVIDARUM AND STRIA ALBICANS PRESENT. NO DISTENDED VEINS OR
ANY SCAR MARKS OR HERNIATION.
• AUSCULTATION:
FETAL HEART SOUND HEARD
 OBSTETRIC EXAMINATION

PALAPTION:
THE SYMPHYSIOFUNDAL HEIGHT WAS 24 CM. ON FIRST LEOPOLD, SOFT,
IRREGULAR KNOB LIKE STRUCTURE WERE PALPABLE SUGGESTING FETAL LIMBS
AND LIE TO BE LONGITUDNAL AND PRESENTATION TO BE CEPHALIC. ON SECOND
LEOPOLD, SMOOTH CURVED PART FELT ON RIGHT SIDE PROBABLY THE FETAL
SPINE.NO FINDINGS ON THIRD, GLOBULAR PART FELT WHICH WAS SUGGESTIVE OF
FETAL HEAD. ON FOURTH LEOPOLD, GLOBULAR HARD PART FELT WHICH WAS
BALLOTABLE SUGGESTING FETAL HEAD.
 PROVISIONAL DIAGNOSIS

• 23 YR OLD PATIENT G2P1A0L1 WITH 27 WEEKS 1 DAY PERIOD OF GESTATION

PRESENTED WITH FATIGUE AND BREATHLESSNESS ON EXERTION AND HAD
PALLOR ON EXAMINATION HAVING SINGELTON PREGNANCY IN CEPHALIC
PRESENTATION SUGGESTIVE OF ANEMIA
 INVESTIGATIONS

• CBC
• SERUM FERRITIN
• PERIPHERAL BLOOD SMEAR EXAMINATION
• LIVER FUNCTION TEST
• STOOL EXAMINATION
 TREATMENT

• IRON THERAPY:
ORAL IRON: FERROUS SULPHATE 200 MG AND FOLIC ACID 0.5 MG TWICE DAILY TILL
HB BECOMES NORMAL
• NON PHARMACOLOGICAL ADVICE:
TO TAKE IRON RICH FOODS LIKE SPINACH, JAGGERY, BAJRA, JOWAR ETC
TAKE IRON TABLETS 1 HOUR BEFORE FOOD WITH LEMON WATER AND AVOID
TAKING IT WITH TEA, COFFEE AND WITH CALCIUM TABLETS