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 comments on comment box is welcome.
CASE HISTORY :
Blood grouping :
TREATMENT :
A 70 year old male patient came to the opd on 4-09-21 with
CHIEF COMPLAINTS :
Weakness since 3 months
Shortness of Breath since 3 months
History of Present Illness:
Patient was apparently asymptomatic 3 months back when he developed weakness on walking for short distances (4-5 steps) and shortness of breath (grade 3) which was aggravated on walking and relieved on taking rest.
He then visited an RMP who checked that he had pallor and asked him to get a blood test done. He then went to the hospital where he was diagnosed with anemia and was given 3 blood transfusions on alternate days. He was asked to come for a follow up after 20 days during which they noticed that there was no rise of hemoglobin despite the transfusions. He was then referred to our hospital.
PAST HISTORY:
History of cataract surgery 10 years back.
History of injury to left leg 5 years back.
History of monkey bite 1 month back.
Not a known case of Diabetes mellitus, Hypertension, Epilepsy, Asthma, Kidney disease.
PERSONAL HISTORY:
Diet : mixed
Appetite : Normal
Sleep : adequate
Bowel and Bladder : An episode of blood in urine was noticed 2 days after the transfusion. Bowel and bladder movements are regular.
Addictions : None
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative and is well oriented to time, place and person.
The patient is thinly built and moderately nourished.
Pallor - Present
Icterus - Absent
Cyanosis- Absent
Clubbing - Absent
Lymphadenopathy- Absent
Edema - Pedal edema in the left leg upto the level of calf which is increased on walking and decreased on taking rest.
VITALS:
At the time of admission:
Temperature: Afebrile
Pulse rate : 91 bpm
Respiratory Rate: 20 cpm
Blood Pressure: 110/70 mm Hg on left arm
GRBS : 150 mg%
Systemic Examination:
CVS : S1, S2 heard
RS : 18cpm
PA : Normal
CNS : Sensory and motor systems are normal
PROVISIONAL DIAGNOSIS:
Pancytopenia
INVESTIGATIONS:
Hemogram :
Serum Iron :
Reticulocyte count :
LDH :
Liver function test :
Blood grouping :
TREATMENT :
On 4-9-21:
1. Inj. Methylcobalamine 1000 microgram/IM/OD
2. Inj. Iron Sucrose 1 amp in 100 ml NS/IV/OD after test dose
3. Vitals monitoring
On 5-9-21:
1. Inj. Methylcobalamine 1000 microgram/IM/OD
2. Inj. Iron Sucrose 1 amp in 100 ml NS/IV/OD after test dose
3. Vitals monitoring
On 6-9-21:
1. Inj. Methylcobalamine 1000 microgram/IM/OD
2. Inj. Iron Sucrose 1 amp in 100 ml NS/IV/OD after test dose
3. Vitals monitoring
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