33 year old Female with hematemesis ,iron deficiency anemia

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 Patient came with chief complaints of bleeding from nose and mouth since 2 months 

HOPI : Patient was apparently normal 2 months back then she had sudden bleeding from nose and mouth , sudden in onset, subsided by medication 

She then had another episode 1 month back 

H/O clots from mouth and nose 

H/o easy fatiguability , shortness of breath grade 2 , generalised weakness , decreased appetite .

C/o neck  pain,  burning sensation in the abdomen , belching present 

No c/o chest pain, palpitations, orthopnea, PND

No H/o menorrhagia, hemturia ,  hemoptysis,blood in stools ,  weight loss .

C/o lower back ache, 

No c/o fever, loose stools, pain abdomen , vomitings, constipation 

Past history : 

Patient is N/K/C/O DM , TB ,Asthma,  Hypertension , epilepsy ,CVA, CAD, Thyroid disorders . 

Personal history 

Diet mixed 

Appetite decreased

Bowel and bladder regular 

Sleep decreased 

Addictions none 

Allergies none 

Family history : Not significant 

Menstrual history  regular cycles 

1-2 /23-24 day cycle

No.of pads per day 1 or 2

Clots size of about 3x3 cm

Pain  present 

General physical examination: 

Patient is conscious, coherent , cooperative well oriented to time, place, person

Pallor present 

No signs of clubbing, icterus, cyanosis, lymphadenopathy, edema of feet  

Vitals at the time of examination : 

Temp : afebrile 

Bp 90/60 mm hg 

RR : 19 cpm 

PR 96 Bpm 

Grbs : 

Spo2 : 98 % at RA 


                          Pallor 

          

        


No icterus 



Koilonychia 








Systemic examination : 

Cvs : s1 and s2 heard 
No murmurs ,
CNS : no focal neurological deficits noted 
Respiratory system : NVBS heard no adventitious sounds 
P/A : soft , non tender no organomegaly 


Investigations : 




































Usg abdomen and pelvis : 






Upper GI ENDOSCOPY 


Referral ent I/v/o bleeding from nose 







Provisional diagnosis : ? Hematemesis  

Iron deficiency anemia 

Treatment given : 
Tab.  LIVOGEN  100 mg  PO/OD  8 am in the morning 

Tab .  ALBENDAZOLE 400 mg  PO/STAT 


Tab.MVT PO/OD 2 PM 


Tab .SHELCAL  500 mg PO/OD 







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