1801006076 - SHORT CASE

 This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients' clinical problems with the 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 are 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, and investigations, and come up with a diagnosis and treatment plan.



CASE PRESENTATION

27 yr old male came with complaints of

Generalised weakness since 10 days

Difficulty in breathing since 10 days

Easy fatigability since 10 days

HOPI: patient was apparently asymptomatic 10 days back he developed generalised weakness insidious in onset, gradually progressive

Shortness of breath of grade 2 

Easy fatigability present

No c/o fever, nausea, vomiting, chest pain, pain abdomen, blood in stools, loose stools, sweating

1 year back, then he developed jaundice and generalised weakness for which he took herbal medicines for 10 days and was resolved.

Not a k/c/o DM/HTN/TB/ Epilepsy/CVA/CAD/Asthma

Personal history:

decreased appetite since 5-6 months

Takes vegetarian diet

Bowels and bladder habits are regular

Disturbed sleep 

Occassional alcohol drinker stopped 1 year back

General examination: patient is c/c/c

Pallor and icterus is present

No signs of cyanosis, clubbing, lymphadenopathy, pedal edema
 

VITALS :
Temp: afebrile

PR: 106 bpm

RR: 20 /min

BP: 130/90 mm hg

Systemic examination:

CVS: S1 S2 heard

RS: Bilateral air entry present

CNS: NFND

P/A: soft, non tender, no organomegaly

Bowel sounds heard

Investigations:
Hemogram :
- Hemoglobin 7.6 gm/dl
- Red cell count 2.2 ml/cu.mm
- WBC Total count 3500ml/cu.mm
Differential Count :
- Neutrophils : 55%
- Lymphocytes : 40%
- Eosinophils : 1%
- Monocytes : 4%
- Basophils : 0%
Platelet count : 1,11,000/cu.mm
Hematocrit :25.3%
MCV : 115 m.micrograms
MCH : 34.5 m.micrograms
MCHC : 30%

COMPLETE URINE EXAMINATION :
Colour : Pale yellow
Appearance : Clear
Reaction : Acidic
Sp. Gravity : 1.010
Albumin : Nil
Sugar : Nil
Bile salts : Nil
Bile Pigments : Nil
Pus cells : 2-3
Epithelial cells :2-3

LFT :
Total Bilirubin : 1.02mg/dl
Direct Bilirubin : 0.03mg/dl
SGOT / AST : 96IU/L
SGPT/ALT : 29 IU/L
A/G ratio : 1.42

Serum Creatinine : 0.7mg/dl
Blood Urea : 24mg/dl

PERIPHERAL BLOOD SMEAR
RBC : Anisopoikilocytosis with microcytes macrocytes normocytes teardrops pencil forms
WBC : Within normal limits
Platelets : Adequate



ECG




Chest x ray



Provisional Diagnosis: 
Anemia secondary to Vitamin B12 deficiency iron deficiency (dimorphic)

 Treatment: 

Inj. VITCOFOL 1000mg/IM/OD


27 year old male came with c/o generalised weakness and shortness of breath since 10 days

S 
1 fever spike 


O
Pt is c/c/c 
BP-130/70 mmhg 
PR- 92bpm
Temp- 98.5F
CVS- S1,S2 heard, no murmurs 
RS- B/L Air entry present
P/A: soft, non-tender 
CNS: HMF intact, NFND  

A
Anemia Secondary to B-12 deficiency and Iron deficiency (Dimorphic) with Tinea Corporis ET Cruris +Statis Dermatitis
 
P: 
Inj. VITCOFOL 1000mg/IM/OD
LULIFIN CREAM L/A BD
LIQUID PARAFFIN L/A BD
TAB. TECZINE 5mg SOS




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