CASE PRESENTATION

1. Case on Idiopathic hemolytic
anemia
R.Anusha
Pharm D VI Year
Roll No:170514882007.

2. Patient Name:Mrs.N
Gender:Female
Age:24 years
IP No:285197
DOA:18/10/19
DOD:20/10/19

3. SUBJECTIVE
• Chief Complaints: Fever since 4 days continuous/moderate
grade fever associated with vomiting.
• Present Illness History: H/o cough since 4 days.
• No H/o expectoration. CBP done outside, found to have high
WBC count, So came here for further management.
• Past medical/medication history: K/c/o HB 4 disease,
s/p status post splenectomy 13years ago
On
T.FOLVITE 1 tab PO BD
T.PENTIDS 400 mg PO BD
• Allergies: NKDA.

4. OBJECTIVE
PHYSICAL APPEARANCE:
Height: 155 cms
Weight: 45 kgs
B.M.I: 18.7 kg/m2
VITALS:
Patient alert, conscious
PALLOR
B.P: 120/70 mmHg.
R.R: 20 breaths/min.
P.R: 96 beats/min.
Temperature: 98.40F
CVS:S1S2+
P/A:Soft, non tender
CNS:NFND

5. Diagnostic test:
• Hb:7.2 gm
• WBC: 54,900
• Platelets:WNL
• Sr.Fe: 106(50-170)
FINAL DIAGNOSIS: Acute febrile illness,
K/c/o HB4 disease, s/p splenectomy,
Idiopathic hemolytic anemia, ?Leukemia
CUE:WNL
Cr. :WNL
Electrolytes:WNL
• SGPT/SGOT: WNL
• LDH: High
978(100-190)

6. DRUG CHART
Brand Generic Dose ROA Freq. Category Indication
IVF NS
18/10/19 -
20/10/19
Normal saline 80 ml/hr IVF Onflow Electrolyte Hydration
Inj.Magnex forte Cefaperazone
sulabctum
1.5gm IV BD Antibiotic Infection
prophylaxis
Inj.Pan Pantoprazole 40 mg IV OD PPI APD
Inj.MVI Multivitamin 1amp in
IVF NS
IV Over 5
hrs
Nutrition
supplement
Nutrition
Inj.Zofer Ondasetron 4 mg IV BD Anti emetic Vomiting
T.Folvite
19-20
Folic acid 5 mg PO OD Iron
supplement
HB4 disease
T.Dolo Paracetamol 650 mg Po SOS Anti pyretic Fever

7. ASSESSMENT
Mrs.N. 24yof came to er with complaints of fever/dry cough
since 4 days.
She is a known case of HB 4 disease status splenectomy 12 yrs
ago.
At the time of admission, patient had normal temperature,
PR and BP.She appeared pallor.
Evaluated with relevant investigations which showed severe
anemia , very high wbc count,platelet count normal,electrolytes
normal

8. • She was treated with IV antibiotics,IV Fluids,MVI and folic
acid supplementation.
• In view of low HB, she received 1 unit of PRBC transfusion.

9. • For high WBC count, hematologist opinion was obtained.
• There was no evidence of Leukemia in hematologist opinion.
• With the above treatment she improved symptomatically.
• Her fever subsided, WBC count decreased.
• She became stable.
• She is being discharged with the following advices.

10. PLAN
MONITORING PARAMETERS:
Monitor CBP

11. Drug related:
• Augmentin 625 mg 1 tab TID PO after food for 7 days.
• Pan 40 mg 1 tab OD PO BBF for 7 days.
• Folvite 5 mg 1 tab OD PO after food till review
• Romilast 10 mg 1 tab OD PO after food till review given for
itching.
Review after 7 days in medical OPD with CBP report.