A 60F with Megaloblastic anemia

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Hi!! This is Vijaya ratna ,9th sem Medical student.This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

DOA - 27/11/2023

CHIEF COMPLAINTS
Fever since 1 week
Palpitations since 1 week 
Generalised weakness since 4 days 
Chest pain and tightness since 4 days

HISTORY OF PRESENTING ILLNESS 
The patient was apparently asymptomatic 1 week ago and then she developed fever which is sudden in onset, high grade, associated with chills and rigors, relieved temporarily on medication. 
Palpitations are present since 1 week which are regular and associated with chest discomfort.
There is H/o shortness of breath on exertion which is progressive (grade 2 to grade 3). No orthopnea, or PND.
There is associated generalised weakness since 4 days and blood in stools since 3 days. 
There is no h/o vomitings, loose stools, pain abdomen, giddiness.

PAST HISTORY
N/k/c/o DM, HTN, Asthma, TB, Epilepsy, CAD, CVA
There is h/o tubectomy 

PERSONAL HISTORY 
Diet mixed 
Appetite normal
Sleep adequate
Bowel & Bladder movements regular 
Addictions - None

GENERAL EXAMINATION 
Pt is conscious, coherent and cooperative and well oriented to time, place and person. 
No cyanosis, clubbing, lymphadenopathy and edema
Pallor present 
Icterus present 
No signs of cyanosis,clubbing,lymphadenopathy,pedal edema

Vitals on admission 
Temp - 98F 
BP - 130/70 mm hg 
PR - 98bpm 
RR- 22cpm 
Grbs - 131mg/dl 
SpO2 - 90% @ RA 

SYSTEMIC EXAMINATION 
CVS - S1 loud, S2 heard, JVP raised, systolic murmur present 
RS - trachea - central , bilateral air entry +, NVBS heard, no added sounds 
PER ABDOMEN - soft, non tender, hepatomegaly present, bowel sounds heard 
CNS - NFND 
INVESTIGATIONS
PROVISIONAL DIAGNOSIS 
Megaloblastic Anemia 

TREATMENT 
27/11/23

1 unit PRBC Transfusion 
Inj Pan 40mg IV OD
Inj Iron sucrose 200mg in 100ml NS IV OD
Inj Vitcofol 1500mg in 100ml NS IV OD
Strict I/O charting, monitor vitals, inform sos 

28/11/23

1 unit PRBC transfusion 
Inj Ceftriaxone 2g IV BD
Cap Doxycycline 100mg PO BD
Inj Pan 40mg IV OD
Inj Iron sucrose 200mg in 100ml NS IV OD
Inj Vitcofol 1500mg in 100ml NS IV OD
Strict I/O charting, monitor vitals, inform sos 


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