A 60F with Megaloblastic anemia

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