MINISTRY OF EDUCATION AND SCIENCE OF THE RUSSIAN

FEDERATION
PENZA STATE UNIVERSITY
“Approved”
Head of Department of “Internal Medicine”
M.D, Professor
Rakhmatullov F.K

TASK
on course work on discipline «Intermediate Level Therapy, occupational diseases»
topic: « ANEMIA »

Student: MADLANI HET KEYUR Group 20LL5(a)

Patient: A, Department of Therapy.

The structure of the course work

Registration of case history (according to the scheme of case history)
Writing at least 5 prescriptions from each group of medicines for the treatment of
the underlying disease, co morbidities and their complications.
The task was got on: 10.09.2025
The deadline – not later than 24.04.2025.
Head – Sheina A.E
MINISTRY OF EDUCATION AND SCIENCE OF THE RUSSIAN
FEDERATION
PENZA STATE UNIVERSITY
Department of “Internal Medicine”

Course work
on discipline «Intermediate Level Therapy, occupational diseases»
on the topic of « Anemia »

Direction of training - 31.05.01 “Faculty of General Medicine”

Graduate's qualification - Medical doctor

Performed by student: Totani Komal Ratan

Group: 20LL5a
Head: Ph. D., Sheina A.E
Work protected rating:
Teachers:

Date: 10.09.2025

2025
 CASE HISTORY

Patient name: А.

Main disease: Severe Polydeficiency Anemia. Cancer alert?

Background disease: Arterial Hypertension stage 3, risk 4. CHF stage 1.
Сomplete right bundle branch block. Diabetes mellitus type 2 insulin-dependent. The
target value of glycated hemoglobin <8%. Diabetic proliferative retinopathy of both
eyes. Bronchial Asthma, exacerbated.

I. PASSPORT DATA

Name: A

1. Date of birth: 15.03.1935 (90 yrs)

2. Sex: Female

3. Place of work: Does not work

4. Diagnosis at admission:

Preliminary diagnosis:

Concomitant disease: Asthma, Diabetes Mellitus type 2

5. Clinical diagnosis:

Main clinical diagnosis: Anemia stage 3

Complaints: General, Fatigue, weakness, low energy, Pallor (skin, conjunctiva,

nails), Dizziness or lightheadedness, Shortness of breath even on rest, Cold
intolerance, Headaches, difficulty concentrating, Sleepiness or confusion

Background disease: Arterial Hypertension stage 3, risk 4. CHF stage 1.

Сomplete right bundle branch block. Diabetes mellitus type 2 insulin-

dependent. The target value of glycated hemoglobin <8%. Diabetic proliferative
retinopathy of both eyes. Bronchial Asthma, exacerbated.

Comorbidities: Asthma, Diabetes Mellitus type 2

Date of admission to the clinic: 08.09.2025

II. MEDICAL HISTORY

1. COMPLAINTS - General, Fatigue, weakness, low energy, Pallor (skin, conjunctiva,

nails), Dizziness or lightheadedness, Shortness of breath even on rest, Cold
intolerance, Headaches, difficulty concentrating, Sleepiness or confusion (especially
in the elderly),Cardiac/Respiratory, Palpitations, ,Tachycardia (fast
heartbeat),Orthopnea or worsening shortness of breath, Neurological /Cognitive,
Memory decline or worsening dementia symptoms, Irritability, mood changes.

2. HISTORY OF PRESENT ILLNESS (ANAMNESIS MORBI)

Mrs. A is a 90-year-old female, a known case of type 2 diabetes mellitus for the past
25 years on oral hypoglycemics, who presented with complaints of progressive
weakness, easy fatigability, and generalized body malaise for the last 3 months.

She reports shortness of breath on exertion, which has gradually worsened from
climbing stairs to occurring even with minimal household activity. She also complains
of dizziness, occasional palpitations, and decreased exercise tolerance. There is history
of pallor and poor appetite, along with unintentional weight loss of ~3 kg over 2 months.

She denies chest pain but notes intermittent leg swelling and orthopnea. No history of
syncope, recent infections, or gastrointestinal bleeding (melena/hematemesis).
Her past medical records indicate stage 3 anemia, likely multifactorial (anemia of
chronic disease with possible nutritional deficiency). She was recently found to have
right bundle branch block on ECG, associated with episodes of mild exertional dyspnea
and fatigue, but no documented arrhythmias or syncope.

Her diabetes has been sub optimally controlled, with occasional episodes of
hyperglycemia. No history of diabetic nephropathy requiring dialysis, but she has mild
peripheral neuropathy.

There is no history of smoking, alcohol use, or major surgeries. Family history is non-
contributory.

HISTORY OF LIFE (ANAMNESIS VITAE)

Brief biological data: Patient A, born on 15/03/1935

Labour history: not working, no disability benefits required.

Household history: Housing and sanitary conditions are satisfactory. She denies
being in an environmental disaster zone. Climatic conditions are favorable.

Meals: balanced, regular, 3 times a day.

Bad habits: Nothing

Transmitted diseases: Infrequent colds without complications.

Chronic Diseases: Diabetes Mellitus Type 2, Asthma.

Epidemiological history: Denies contact with infectious and febrile patients the last
month. Denies staying in an endemic or epizootic focus, no insect or animal bites.
Has not travelled outside Penza region in last month. Blood and its components were
transfused. Denies TB, viral hepatitis, syphilis, HIV, PUD.

Surgical interventions: Inguinal hernia

Allergy history: Pollen allergies

Heredity: Not burdened.

III DATA OF OBJECTIVE EXAMINATION

1. General examination
General Condition:
The patient is in a moderate condition but conscious, alert, . Her body type is
hypersthenic.

Anthropometrics: Weight: 95kg. Height: 166 cm. BMI: 34.5 kg/m² – Obese class 1.
Waist circumference: 95 cm. BSA: 2.09 m²

Vital Signs:

- Body temperature: 40 °C – slightly elevated.

- RR: 12 per minute, Oxygen saturation: 92%

- HR: 69 bpm

- BP: lying – 100/65 mmHg, standing – 95/60 mmHg, sitting – 100/65 mmHg

Skin, Nails, and Mucous Membranes:

 - Skin is clean, pale, and moderately dry.

- No signs of rashes, pigmentation, infections, wounds, or ulcers.

- No visible tumors or abnormal tissue.

- Mucous membranes look normal, and cyanosis present.

- Hair distribution is typical for a female, some expected age-related hair thinning
and graying, but no patchy hair loss.
- Nails appear normal in shape and texture, without brittleness.

Subcutaneous Fat:
- Fat tissue is evenly distributed, normal in texture, with no signs of
inflammation or damage.
- Edema noted on the legs or feet.

Lymphatic System:

- Lymph nodes in all major regions (neck, underarms, groin, etc.) are palpable
but normal in size, soft, mobile, and not painful.
- Skin over the nodes is healthy.

Musculoskeletal System:

- Bones: Normal size and shape, no deformities or tenderness.

- Muscles: Muscle weakness and fatigue.

- Joints: Restricted movements.

2. Respiratory System

Chest is normal shaped. Type of breathing - chest. Respiratory rate - 12 per minute.
Oxygen saturation – 92%.

Percussion of the lungs: In comparative percussion there was a clear pulmonary

sound over all pulmonary fields.

Findings of topographic percussion:

• The height of the apex pulmonis standing: Right Front - 3 cm above the clavicle,
front left - 3.5 cm above the clavicle, behind - at the level of the spinous process of
VII cervical vertebra.

• Krenig's area widths: right - 6.5 cm, left - 6 cm;

• Borders of the lungs:

Topographic lines Right Left

Parasternal V interspace -

Midclavicular VI rib -

Anterior axillary VII rib VII rib

Midaxillary VIII rib VIII rib

Posterior axillary IX rib VIII rib

Scapular X rib IX rib

Spinous process of the XI Spinous process of the XI

Paravertebral thoracic vertebra thoracic vertebra

In the lungs, the breathing is vesicular and without rales.

3. Cardiovascular system
1. Pulse / Arterial System

Rate: 60 bpm → bradycardia (at the lower end of normal).

Rhythm: Regular sinus rhythm.

Volume: Normal to low volume (may be reduced due to anemia).

Character: Typically normal; no collapsing or slow-rising pulse expected with isolated

RBBB.

Radio-femoral delay: Absent.

All peripheral pulses palpable.

2. Venous System (Jugular Venous Pulse – JVP)

JVP: Not elevated (unless there is associated right heart failure).

Waveform: Normal a, c, v waves. No cannon waves.

Hepatojugular reflux: Negative (unless right-sided dysfunction progresses).

3. Palpation

Apex beat: Located in the 5th intercostal space, mid-clavicular line; not displaced
(unless cardiomegaly or LV hypertrophy present).

Character: Normally palpable, not heaving or thrusting.

Thrills: None palpable.

Parasternal heave: Usually absent; may appear if long-standing RBBB is associated

with right ventricular hypertrophy.

Palpation of heart sounds: S1 and S2 palpable in carotids, no abnormal thrills.

4. Percussion

Cardiac borders: Normally within expected limits (percussion is less reliable in

elderly, but traditionally):

Right border: 1 cm to the right of sternum at 4th ICS.

Left border: At or just medial to MCL in 5th ICS.

Upper border: At 2nd ICS.

Findings: No significant cardiomegaly.

5. Auscultation (for completeness in project)

S1 & S2: Normal intensity.

Splitting of S2: Wide, fixed splitting can be seen in RBBB due to delayed RV
activation.

Murmurs: No pathological murmurs unless associated valvular disease present.

Gallops: None typically.

4. Digestive system

Age-Related Changes:
1. Decreased digestive enzyme production: Reduced production of digestive enzymes
can impair nutrient absorption.
2. Slower gut motility: Aging can lead to slower movement of food through the
digestive system.
3. Changes in gut microbiota: Alterations in the gut microbiome can affect nutrient
absorption and overall health.

Anemia-Related Changes:
1. Reduced appetite: Anemia can lead to decreased appetite, potentially exacerbating
malnutrition.
2. Impaired nutrient absorption: Anemia can impair the body's ability to absorb essential
nutrients, including iron, vitamin B12, and folate.

Potential Digestive Issues:

1. Constipation: Slower gut motility and decreased physical activity can contribute to
constipation.
2. Malabsorption: Impaired nutrient absorption can worsen anemia and overall health.
3. Gastrointestinal bleeding: Certain underlying conditions, such as gastrointestinal
ulcers or cancer, can cause bleeding and contribute to anemia.

5. Endocrine System
There is no visible increase in thyroid gland. Symptoms of hyperthyroidism and
hypothyroidism are absent. Lack of changes in face and limbs that are characteristic for
acromegaly. No apparent hair loss.

6. Nervous System

Consciousness: clear, state of mind not disturbed and oriented.

The emotional background is calm. The emotional reaction to conversation with the
doctor is normal, the patient is easy to contact and has friendly speech. The patient
understands and responds adequately when spoken to. The purpose of actions is not
disrupted. The response to visual and auditory stimuli is unchanged.
Swallowing, phonation is not impaired. Taste sensitivity has not changed. Sensitivity:
surface and deep sensitivity are preserved. Coordination of movements. Meningeal
symptoms: none.
Vegetative functions: without pathological changes. understands and responds
adequately when spoken to. The purpose of actions is not disrupted. The response to
visual and auditory stimuli is unchanged.

IV PRELIMINARY DIAGNOSIS AND ITS RATIONALE

DIAGNOSIS: Severe Polydeficiency Anemia. Cancer alert?

Concomitant diseases: Asthma, diabetes mellitus type 2.

Complication: General, Fatigue, weakness, low energy, Pallor (skin, conjunctiva, nails),
Dizziness or lightheadedness, Shortness of breath even on rest, Cold intolerance,
Headaches, difficulty concentrating, Sleepiness or confusion (especially in the
elderly),Cardiac/Respiratory, Palpitations, ,Tachycardia (fast heartbeat),Orthopnea or
worsening shortness of breath, Neurological /Cognitive, Memory decline or worsening
dementia symptoms, Irritability, mood changes, Falls due to dizziness or weakness,
thrombocytopenia, neutropenia, leukocytopenia.

Complaints: Anamnesis morbi:

Patient A is a 90-year-old female, a known case of type 2 diabetes mellitus for the
past 25 years on oral hypoglycemics, who presented with complaints of
progressive weakness, easy fatigability, and generalized body malaise for the last
3 months.She reports shortness of breath on exertion, which has gradually
worsened from climbing stairs to occurring even with minimal household
activity. She also complains of dizziness, occasional palpitations, and decreased
exercise tolerance. There is history of pallor and poor appetite, along with
unintentional weight loss of ~3 kg over 2 months. She denies chest pain but notes
intermittent leg swelling and orthopnea. No history of syncope, recent infections,
or gastrointestinal bleeding (melena/hematemesis).Her past medical records
indicate stage 3 anemia, likely multifactorial (anemia of chronic disease with
possible nutritional deficiency). She was recently found to have right bundle
branch block on ECG, associated with episodes of mild exertional dyspnea and
fatigue, but no documented arrhythmias or syncope. Her diabetes has been sub
optimally controlled, with occasional episodes of hyperglycemia. No history of
diabetic nephropathy requiring dialysis, but she has mild peripheral neuropathy.
There is no history of smoking, alcohol use, or major surgeries. Family History is
non-contributory.
Physical Examination: On examination, the patient is in a condition of moderate
severity with clear consciousness and full orientation. Vital signs are stable, with
blood pressure at 100/65 mmHg, heart rate 69 bpm, and respiratory rate 12/min.
Oxygen saturation (92%). Cardiac examination reveals rhythmic, clear tones
without pathological murmurs or signs of decompensation (Killip I). Respiratory
function is adequate, with vesicular breath sounds throughout and no wheezing
or rales. The abdomen is soft and non-tender, and there are no signs of fluid
retention or peripheral edema. Her body weight and constitution (95 kg at 166 cm,
BMI 34.5 kg/m²) suggest a hypersthenic build with obese class 1, contributing to
 cardiovascular risk.
V PLAN OF EXAMINATION

Laboratory examination:

1. Complete Blood Count (CBC): routine analysis

2. Urinalysis: routine analysis. To determine hypertension mediated organ

damage and rule out proteinuria and albuminuria.
3. Biochemical analysis: Fasting glucose – rule out DM, Lipid profile –
determination of risk factors, Electrolytes (Sodium and Potassium) – rule out
secondary causes of hypertension, Uric acid (BUN) – determine risk factors
of AH, Creatinine, urea – determine function of kidneys. AST, ALT, total
bilirubin – rule out concomitant diseases.
4. Blood test for serum iron, ferritin, transferin, Serum Total Iron Binding
Capacity (TGSS)
5. Vitamin B12 blood test
6. Fecal occult blood test
7. Blood type and Rh factor test

Instrumental examination:

1. Electrocardiogram (ECG): To assess for signs of myocardial ischemia,

infarction (new or old), arrhythmias or conduction abnormalities.
2. Echocardiogram: To evaluate left ventricular function, wall motion
abnormalities, valve integrity and to rule out heart failure or structural changes.
3. Chest X-ray: Assess silhouette of the heart and pulmonary circulation.
4. Fibrogastroduodenoscopy
5. Fibrocolonoscopy
6. Ultrasound of the kidneys
 7. Ultrasound of the abdominal cavity.

VI RESULTS OF LABORATORY TESTS

Complete Blood Count (CBC) Post-transfusion

Blood group – A2+

• WBC: 7.94 × 109 /L • RBC: 1.72 x 1012 /L

• LYMPHOCYTES: 45.8% • HGB: 59 g/l

• MONOCYTES: 5.8% • HCT: 18.3 %

• NEUTROPHILS: 39.1% • MCV: 106.4 fl

• EOSINOPHILS: 6.1% • MCH: 34.3 pg

• BASOPHILS: 2.5% • MCHC: 322 g/L

• LY, absolute: 1.27 x 109 /L • RDW: 24.8%

• MO, absolute: 0.16x 109 /L • RDW-SD: 92.5fl

• NE, absolute: 1.08x 109 /L • PLT: 100× 109 /L

• EO, absolute: 0.17 x 109 /L • MPV: 12.8 fl

• BA, absolute: 0.07 x 109 /L

Conclusion: Thrombocytopenia, leukocytopenia, Anemia.

Complete Blood Count (CBC) Pre-transfusion

• WBC: 3.10 × 109 /L
• LYMPHOCYTES: 42.2%
• MONOCYTES: 9%
• NEUTROPHILS: 36.8%
• EOSINOPHILS: 5.8%
• BASOPHILS: 3.2%
• LY, absolute: 1.37x 109 /L
• MO, absolute: 0.28x 109 /L
• NE, absolute: 1.37x 109 /L
• EO, absolute: 0.18x 109 /L
• BA, absolute: 0.18 x 109 /L
• RBC: 1.72 x 1012 /L
• HGB: 57 g/l
• HCT: 17.8 %
• MCV: 183.5 fl
• MCH: 33.1 pg
• MCHC: 320 g/L
• RDW: 24.9%
• RDW-SD: 89.9fl
• PLT: 103× 109 /L
• MPV: 12.8 fl

Conclusion: Thrombocytopenia, neutropenia, leukocytopenia , Anemia.

Urinalysis:
 8 September 2025

• Color: pale yellow

• Clarity: Transparent

• Relative density: 1.003 g/ml

• Protein: absent

• Ketones: absent

• Sugar: absent

• Urobilinogen: --

• Bilirubin: --

• Leukocytes: 0-2

• Squamous epithelium: 2-3

• Bacteria: absent

• Salts: absent

Conclusion: Normal

Metabolic panel:
 8 September 2025

• Total protein: 72.0 g/L

• Urea: 9.8 mol/L

• Creatinine: 100 mg/L

• Uric acid: --

• Total bilirubin: 22 μmol/L

• AST: 16 Eg/l

• АЛТ: 11

• LDG: 492 Eg/l

• Glucose: 6.4 mmol/L

• Alkaline phosphatase 105 U/l

• CRP 2.0 g/l

• Gamma-GTP 58.0 U/L

• Iron 29.8 μm/L

• Ferritin 188 μg/l

• Transferin 2.3 g/l

Conclusion: increased urea, bilirubin
LDG Glucose, C reactive protein,
gamma GTP, ferritin decreased iron
and transferrin.

Fecal occult blood test:

Feces on worm eggs were not found

Occult Blood +

Electrocardiogram:
Echocardiogram

Patient: 90-year-old female

Clinical background: Diabetes mellitus, stage 3 anemia, complaints of weakness and
exertional dyspnea.
Heart rate on ECG: 60 beats per minute (regular).

ECG Findings

Rhythm: Sinus rhythm at 60 bpm.

P waves: Present, upright in lead II, preceding each QRS complex.

PR interval: Normal (~0.12–0.20 s).

QRS complex: Prolonged (>120 ms).

QRS morphology:

rsR’ pattern in lead V1 (“M-shaped” RSR’).

Broad, slurred S waves in leads I, aVL, and V6.

Axis: Normal (may occasionally be right-deviated in RBBB).

ST-T changes: Discordant T wave inversion and ST depression in right precordial leads
(V1–V3), typical of RBBB.
QT interval: Within normal limits
Interpretation

Sinus rhythm at 60 bpm.

Complete Right Bundle Branch Block (RBBB).

Fibrogastroduodenoscopy:

The gastroscope is easily passed through the upper esophageal sphincter. The esophagus
is patent, with no deformities, and foamy mucus in the lumen. Peristalsis is moderate.
Fold relief is normal. The walls are elastic. Tonus is normal. The esophageal mucosa is
pale pink and elastic.

The Z-line is distinct, located 38 cm from the incisors, and the mucosa is hyperemic.
The stenosis corresponding to the esophageal opening of the diaphragm is located 39
cm from the incisors. The cardia closes loosely and rhythmically.

The fasting stomach contains clear fluid and foamy mucus. Peristalsis is visible. The
folds are smooth and can be straightened by air. The mucosa is pale pink, atrophic, and
elastic. The antral region contains protuberances approximately 2 mm in diameter. The
mucosa is edematous and hyperemic.

The pylorus is rounded and closes tightly and rhythmically. The mucosa in the bulb and
postbulbar regions is pale pink and elastic. Whitish lesions, approximately 1-2 mm in
diameter, appear along all walls, resembling semolina. A large amount of bile is present
in the lumen. The pyloric septum area is difficult to examine (end-gap optics) and
reveals no abnormalities.
Ultrasound of the kidneys:

Left kidney

Located, usually in a sitting position, the contours are uneven and unclear
Dimensions: 112-47 mm. Parenchyma thickness in the middle segment is 11 mm
Parenchyma echogenicity is average
Corticomedullary differentiation not broken, NPV expanded
In the sinus, anechoic formations are visualized, with a smooth and clear contour, a
homogeneous structure, providing acoustic amplification, with maximum dimensions
of 20x11 mm.
The adrenal gland is not visualized

Right kidney

Usually located in a sitting position, The contours are uneven and unclear
Dimensions: 108-53 mm. Parenchyma thickness in the middle segment: 13 mm.
Parenchyma echogenicity is average
Carticomedullary differentiation
IC rasirena not broken

Erosions in the sinus anechoic formations are visualized, with a smooth and clear
outline, homogeneous structures, providing acoustic amplification, with maximum
dimensions of 21x14 mm.
The renal gland is not visualized.
Ultrasound signs of sinus cysts in both kidneys

DIFFERENTIAL DIAGNOSIS
The differential diagnosis for anemia includes a broad range of causes, which are
typically categorized by red blood cell size (microcytic, normocytic, or macrocytic) and
mechanism (decreased production, increased destruction, or blood loss).

• Microcytic Anemias:
Microcytic anemias are characterized by a mean corpuscular volume (MCV) less than
80 fL and include:
• Iron deficiency anemia
• Thalassemias (alpha and beta)
• Sideroblastic anemia
• Anemia of chronic disease (can also be normocytic).
Normocytic Anemias:
Normocytic anemias have an MCV of 80–100 fL and include:
• Acute blood loss (trauma, GI bleed, surgery)
• Anemia of chronic disease (inflammation, malignancy)
• Aplastic anemia
• Hemolytic anemias (autoimmune, hereditary spherocytosis, G6PD deficiency,
sickle cell disease)
• Renal failure
• Bone marrow infiltration (myelofibrosis, malignancy).
Macrocytic Anemias:
Macrocytic anemias (MCV >100 fL) are most often due to:
Vitamin B12 deficiency
• Folate deficiency
• Myelodysplastic syndromes
• Liver disease
• Alcohol use
• Hypothyroidism
• Drug-induced causes.
Additional Considerations:
• Hemolytic anemia: Look for evidence of hemolysis (e.g., jaundice, dark urine,
elevated LDH, decreased haptoglobin), and assess for extravascular (spherocytes,
DAT tests) or intravascular causes (schistocytes, mechanical heart valves,
microangiopathy).
• Blood loss: Consider acute trauma, gastrointestinal bleeding, menorrhagia, or
surgical losses.
• Infiltrative/malignant: Suspect in individuals with weight loss, fatigue, or
abnormal peripheral smear findings.
• Pediatric causes: Include anemia of prematurity, parvovirus B19 infection, or
hemolytic conditions specific to children.

VII CLINICAL DIAGNOSIS AND ITS RATIONALE

Main disease:

Complication: General, Fatigue, weakness, low energy, Pallor (skin, conjunctiva,

nails), Dizziness or lightheadedness, Shortness of breath even on rest, Cold
intolerance, Headaches, difficulty concentrating, Sleepiness or confusion

Background disease: Arterial Hypertension stage 3, risk 4. CHF stage 1.

Сomplete right bundle branch block. Diabetes mellitus type 2 insulin-dependent.

The target value of glycated hemoglobin <8%. Diabetic proliferative retinopathy of
both eyes. Bronchial Asthma, exacerbated.

Comorbidities: Asthma, Diabetes Mellitus type 2

DIAGNOSIS: Anemia
1. Complaints: General, Fatigue, weakness, low energy, Pallor (skin, conjunctiva,
nails), Dizziness or lightheadedness, Shortness of breath even on rest, Cold
 intolerance, Headaches, difficulty concentrating, Sleepiness or confusion
(especially in the elderly),Cardiac/Respiratory, Palpitations, ,Tachycardia (fast
heartbeat),Orthopnea or worsening shortness of breath, Neurological
/Cognitive, Memory decline or worsening dementia symptoms, Irritability,
mood changes, Falls due to dizziness or weakness, thrombocytopenia,
neutropenia, leukocytopenia.

2. History of present illness: Anemia , Asthma, Diabetes Mellitus type 2.

3. Data of objective examination: On examination, the patient is in a condition of
moderate severity with clear consciousness and full orientation. Vital signs are
stable, with blood pressure at 100/65 mmHg, heart rate 69 bpm, and respiratory
rate 12/min. Oxygen saturation (92%). Cardiac examination reveals rhythmic,
clear tones without pathological murmurs or signs of decompensation (Killip I).
Respiratory function is adequate, with vesicular breath sounds throughout and
no wheezing or rales. The abdomen is soft and non-tender, and there are no
signs of fluid retention or peripheral edema. Her body weight and constitution
(95 kg at 166 cm, BMI 34.5 kg/m²) suggest a hypersthenic build with obese
class 1, contributing to cardiovascular risk.

4. Findings of laboratory investigations: CBC, Urine analysis,

Fibrogastroduodenoscopy.

5. Findings of instrumental examinations:

- ECG: Rhythm: Sinus rhythm at 60 bpm.

- P waves: Present, upright in lead II, preceding each QRS complex.

- PR interval: Normal (~0.12–0.20 s).

- QRS complex: Prolonged (>120 ms).

 - QRS morphology:

- rsR’ pattern in lead V1 (“M-shaped” RSR’).

- Broad, slurred S waves in leads I, aVL, and V6.

VIII TREATMENT PLAN AND ITS RATIONALE

Non-pharmacological regime:
Diet:
Iron-rich foods (green leafy vegetables, beans, lean meat, fortified cereals).
Diabetic diet (low glycemic index, avoid refined sugars).
High fiber (unless active GI bleed).
Hydration: Adequate but avoid overload.

Lifestyle

Regular mild exercise (walking, breathing exercises for asthma) within tolerance.
Weight management (BMI ~34.5 → obesity class I).
Smoking/alcohol avoidance.

Monitoring

Blood glucose monitoring (fasting + post-meal).

Hemoglobin and iron studies every few months.
ECG follow-up for conduction disturbances.
Stool occult blood test/colonoscopy to identify bleeding source.

Pharmacological regime:
Stop/avoid NSAIDs & aspirin (can worsen GI bleeding).
Iron supplementation (oral if tolerated, IV if absorption poor or bleeding ongoing).
Folic acid ± Vitamin B12 (if deficiency suspected).
Proton Pump Inhibitors (PPI) (e.g., pantoprazole) for upper GI bleed or ulcer
protection.
Blood transfusion (if Hb <7 g/dL or symptomatic) → watch for TACO/heart failure
risk.
Treat underlying cause (colonoscopy, GI consult → polyp/cancer/ulcer).

Prescription

1. Tab. Ferrous Sulfate 325 mg

1 tablet orally once daily after meals
(equivalent to ~65 mg elemental iron)
Counsel: take with vitamin C source, avoid tea/coffee with dose

2. Tab. Folic Acid 5 mg

1 tablet orally once daily

3. Cap. Vitamin B12 (Methylcobalamin 500 mcg)

1 capsule orally once daily
(If B12 deficiency suspected — alternate: IM Hydroxocobalamin 1000 mcg once
weekly for 6 weeks, then monthly)

4. Packed Red Blood Cell (PRBC) Transfusion

1 unit if Hb <7 g/dL or symptomatic
Infuse slowly (to prevent TACO)

5. Losartan 100 mg in the morning

6. Amlodipine 5 mg at 17:00
7. Glargin (Toudgeo) 22 units s/c in the morning

IX CLINICAL OBSERVATION

08.09.2025: Complaints: General weakness, General Fatigue, weakness, low energy,

Pallor (skin, conjunctiva, nails), Dizziness or lightheadedness, Shortness of breath even
on rest, Cold intolerance, Headaches, difficulty concentrating, Sleepiness or confusion
(especially in the elderly),Cardiac/Respiratory, Palpitations, ,Tachycardia (fast
heartbeat),Orthopnea or worsening shortness of breath, Neurological /Cognitive,
Memory decline or worsening dementia symptoms, Irritability, mood changes, Falls due
to dizziness or weakness, thrombocytopenia, neutropenia, leukocytopenia.

History of Present Illness: Mrs. A is a 90-year-old female, a known case of type 2

diabetes mellitus for the past 25 years on oral hypoglycemics, who presented with
complaints of progressive weakness, easy fatigability, and generalized body malaise for
the last 3 months.

She reports shortness of breath on exertion, which has gradually worsened from
climbing stairs to occurring even with minimal household activity. She also complains
of dizziness, occasional palpitations, and decreased exercise tolerance. There is history
of pallor and poor appetite, along with unintentional weight loss of ~3 kg over 2 months.

She denies chest pain but notes intermittent leg swelling and orthopnea. No history of
syncope, recent infections, or gastrointestinal bleeding (melena/hematemesis).

Her past medical records indicate stage 3 anemia, likely multifactorial (anemia of
chronic disease with possible nutritional deficiency). She was recently found to have
right bundle branch block on ECG, associated with episodes of mild exertional dyspnea
and fatigue, but no documented arrhythmias or syncope.
Her diabetes has been sub optimally controlled, with occasional episodes of
hyperglycemia. No history of diabetic nephropathy requiring dialysis, but she has mild
peripheral neuropathy.

There is no history of smoking, alcohol use, or major surgeries. Family history is non-
contributory.

Past Medical History: Inguinal Hernia

Allergy History: Pollen allergy . Objective Status: Temperature: 36.6°C.
Respiratory rate: 16/min. Heart rate: 69 bpm. Blood pressure: 100/60 mmHg. SpO₂:
92%. BMI: 54.5kg/m2. General condition: Moderate. Glasgow Coma Scale: 15
points; alert and fully oriented. Position: Active. Musculoskeletal system: No
pathological changes. Skin: Pale skin, moderately dry moisture, no rashes.
Subcutaneous fat: severe developed. Edema: visible. Lymph nodes: Not enlarged
or tender. Chest: Normal shape, non-tender on palpation. Breathing: Spontaneous,
unlabored. Lungs (Percussion): Resonant. Lungs (Auscultation): Vesicular breath
sounds, evenly heard, no wheezes. Neck veins/arteries: No
abnormal pulsations. Abdomen: Soft, non-tender, not distended. Bowel sounds
present. Liver: Palpable at costal margin, non-tender. Spleen: Not palpable.
Kidneys: Normal, no costovertebral tenderness. Urination: Normal, painless,
regular. Meningeal signs: Not present.

X. PROGNOSIS

The A The prognosis in this patient is guarded. While anemia can improve
with iron therapy, transfusion, and treatment of the bleeding source, her advanced
age, comorbid diabetes, asthma, and RBBB increase the risk of complications such
as heart failure, recurrent bleeding, infections, and functional decline. Long-term
outcomes will largely depend on controlling diabetes, preventing further GI
bleeding, and monitoring for cardiac complications.

XI EPICRISIS

Patient name: А.

Main disease: Severe Polydeficiency Anemia. Cancer alert?

Background disease: Arterial Hypertension stage 3, risk 4. CHF stage 1.

Сomplete right bundle branch block. Diabetes mellitus type 2 insulin-

dependent. The target value of glycated hemoglobin <8%. Diabetic proliferative
retinopathy of both eyes. Bronchial Asthma, exacerbated.

History of present illness:

1. History of present illness: Anemia , Asthma, Diabetes Mellitus type 2.
2. Data of objective examination: On examination, the patient is in a condition of
moderate severity with clear consciousness and full orientation. Vital signs are
stable, with blood pressure at 100/65 mmHg, heart rate 69 bpm, and respiratory
rate 12/min. Oxygen saturation (92%). Cardiac examination reveals rhythmic,
clear tones without pathological murmurs or signs of decompensation (Killip I).
Respiratory function is adequate, with vesicular breath sounds throughout and
no wheezing or rales. The abdomen is soft and non-tender, and there are no
signs of fluid retention or peripheral edema. Her body weight and constitution
(95 kg at 166 cm, BMI 34.5 kg/m²) suggest a hypersthenic build with obese
class 1, contributing to cardovascular risk.

Blood group: A (II), Rh positive

Blood test for Hepatitis, HIV, syphilis, TB: negative

 CBC conclusion: Thrombocytopenia, Leucocytopenia, Neutropenia
Urinalysis: Normal

ECG: Rhythm: Sinus rhythm at 60 bpm.

P waves: Present, upright in lead II, preceding each QRS complex.

PR interval: Normal (~0.12–0.20 s).

QRS complex: Prolonged (>120 ms).

QRS morphology:

rsR’ pattern in lead V1 (“M-shaped” RSR’).

Broad, slurred S waves in leads I, aVL, and V6.

Recommendation:
Non-pharmacological regime:
Diet:
Iron-rich foods (green leafy vegetables, beans, lean meat, fortified cereals).
Diabetic diet (low glycemic index, avoid refined sugars).
High fiber (unless active GI bleed).
Hydration: Adequate but avoid overload.

Lifestyle

Regular mild exercise (walking, breathing exercises for asthma) within tolerance.
Weight management (BMI ~34.5 → obesity class I).
Smoking/alcohol avoidance.
Home Precautions:
1. Tab Ferrous Sulphate 325 mg
2. Tab Folic acid 5mg
3. Cap. Vitamin B12
4. Losartan 100 mg in the morning
5. Amlodipine 5 mg at 17:00
6. Glargin 22 units s/c in the morning

Remark:
Need to go for Fibrocolonoscopy in other place for suspection of cancer.

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