Gen med case presentation;
Feb 11,2022
Name;Ramya reddy pebbeti.
Roll no;105 .
This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients’ clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome.
I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan
Following is the view of my case :
CASE PRESENTATION ;
DOA:10/02/22
chief compliants;
He is a 23 yr old male who is a auto driver by occupation came to the opd yesterday with complaints of ;
Yellowish discoloration of eyes since 15 days
Fever - high grade since 1 week
Abdominal discomfort since 1 week
SOB since 1 week
Blood in stools and burning sensation while passing stools 2 episodes 2 days back
3 years back;
He was apparently asymptomatic 3 yrs back then he got fever for which he went to the hospital where he is found to have pallor and Hb levels were 4gm% for which he received 3 PRBC transfusions and there only they diagnosed him as B12 deficiency anemia for which he received b12 injections and his Hb levels increased to 12gm%.
Now;
He noticed yellowish discoloration of eyes since 15 days and fever , abdominal discomfort (squeezing type)since 1 week for which he went to hospital and received medications and he also took herbal medicine for jaundice
Personal history;
Diet; mixed
Appetite; reduced
Bowel and bladder: regular
Sleep: adequate
He takes beer (2 bottles) twice weekly
General examination;
He is conscious, coherent, cooperative and we'll oriented to time,place,person
Vitals ;
Temp; febrile
PR;80bpm
RR;20cpm
Bp; 110/80 mm ofHg
SPO2; 99%
Pallor and icterus; present
Cyanosis, clubbing, lymphadenopathy-absent
Oedema; upto ankles on both legs
Hyperpigmentation of knuckles is present
Systemic examination;
Per abdomen;
Soft and non tender
No scars ,sinuses and engorged veins
Respiratory system;
BAE+
CVS;
S1,S2 HEARD ,jvp raised and flow murmur
CNS : intact
Investigations;
Reticulocyte count;
Hemogram;
Provisional Diagnosis;
Fever with Pancytopenia
?megaloblastic anemia
Treatment;
On 10/02/22;
Inj methylcobalamin 1500 micrograma in 100 mlNS iv/oD
Inj.lasix 40 mg BD
Inj.pantop 40 mg iv/oD
Inj.zofer 4 mg iv/OD
Tab.ultracet BD
Tab.PCM 500 mg PO
I/O charting
On 11/02/22;
Hemogram;
Hb;3.1 gm%
TLC;3200
PCV;9.1vol%
MCH;33.7
RDW-cv:31.5
RBC;0.92 million/cumm
Platelet;28000/cumm
LFT;
TB;8.04mg/ dl
DB;0.64
AST;61
ALT;17
ALP;72
TP;6.2
ALBUMIN;4.19
A/G ratio;2.08
Serum ferritin;156ng/ml
ESR;30mm-1st hr
Same treatment
Investigations and treatment on 13/2/22;
Hemogram ;
Hb;3.2 g/dl
TLC;4400
PCV;8.9 vol%
MCV;99.4
MCH;35.1
MCHC;35.3
RDW-cv;32.6
Platelet;35000/cumm
RBC;0.90millions/cumm
LFT;
TB;1.84
DB;0.30
AST;50
ALT:13
ALP;65
TP:5.8
Albumin:3.78
A/G RATIO;1.87
No fresh complaints.
Treatment;
Same treatment
On 14/02/22;
He c/o 1 episode of blood in stools for which he is referred to general surgery dept.
Surgery referral;
Treatment ; same treatment along with
# High fibre diet
#Adequate hydration
#Sitz bath for 20 min TID
#Oint.lignocaine for LA/ Bd
#Tab.oxerute-cD /OD/2 days
On 15/02/22; and 16/02/22;
Same treatment
On 17/02/22
Hb;5.9
TLc;3700
pLT;1.5 lakhs
And also same treatment
