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A 60F with megaloblastic anemia

 Nov29, 2023

This is an 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 patient's clinical problems with collective current best evidence based inputs.


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.
IMMANI AASRITHA

Roll no.49

8th semester

Nov 28, 2023

GENERAL MEDICINE

DOA - 27/11/2023

CHIEF COMPLAINTS:

Fever since 1 week

Palpitations since 1 week 

Generalised weakness since 4 days 

Blood in stools since 3 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 movement- Constipation present, Bladder 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 








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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