Medicine E log

Medicine case presentation 

Thursday , 2nd July.

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.

Case Discussion : 

A 35 year old male who works as supervisor in thermal plant, regular to work, resident of dhamadacheela Nalgonda came with chief complaints of : 

1. yellowish discolouration of sclera since 8 days
2. Pain in the infrascapular region radiating to chest in the apical region since 3 days 
3. Normal appetite but not feeling well to take food

HOPI : 

Patient was apparently asymptomatic 8 days back, then he developed yellowish discolouration of sclera for which he used herbal medicine for 2 days (2 tablets) 

Yellow coloured urine is present, no pale coloured stools, No itching. He went to hospital 5 days back used medication for 3 days and he was found having low Hb and jaundice. He noticed cola coloured stools (1 episode). 

Pain in the infrascapular region radiating to chest in the apical region since 3 days which was mild, intermittent, does not increase with hand movements. No H/O SOB, giddiness, syncopal attack. 

No H/O nausea, vomitings, loose stools, fever, cough, cold, pain abdomen, burning micturition, bleeding PR, joint pains, headache. 

History of past illness : 

H/o 15 episodes of loose stools and 2-3 episodes of vomiting for 1 day 15 years back, diagnosed with typhoid. H/o blood transfusion 15 yrs back. 

H/o Fever, jaundice diagnosed with malaria admitted for 2 days. 

No H/o DM, HTN, Asthma, Epilepsy, CAD. 

Drug history : 

Not allergic to any known drug. 

Personal history : 

Diet : mixed

Appetite : Normal 

Sleep : adequate 

Bowel and Bladder : regular

-chronic alcoholic, 2-3 times/month (270ml)

Family history: 

Not significant 

General Examination : 

 

Patient is conscious,coherent and cooperative. Moderately nourished and well built.

Temperature : Afebrile

Pulse rate : 88bpm

BP : 120/90 mm hg

RR : 16 cycles per min 

SPO2 : 98%

GRBS : 121 mg/dl

Signs of pallor and icterus present. 

No signs of cyanosis, clubbing, kilonychia, generalised lymphadenopathy and pedal edema. 

Systemic Examination : 

Respiratory system : 

Normal vesicular breath sounds heard

Bilateral air entry present 

Dyspnoea- no 

Wheeze- no

Position of trachea- central

Breath sounds- vesicular

No Adventitious sounds heard. 

CVS : 

Cardiac sounds : S1 S2 heard 

No murmurs heard 

GI Examination : 

Inspection : 

Shape - obese 

Umbilicus - central 

All quadrants moving equal on respiration 

3 old burn scars are present

No sinuses, dilated veins. 

Palpation : 

Soft, no tenderness, no local rise of temperature

Liver - not palpable 

Spleen - palpable 7cm below coastal margin, enlargement towards umbilicus. 

Percussion : 

Liver - dull note, heard at right 5th ICS in mid clavicular line till coastal margin 

Spleen - dull note heard at left 7th ICS extending 7cm below coastal margin. 

Auscultation : 

Bowel sounds are heard 

CNS : 

Patient is conscious, coherent, cooperative well oriented to time place and person. 

Speech - normal 

No signs of meningeal irritation 

Higher mental functions- normal

cranial nerves- intact 

motor system- normal

sensory system - normal

Reflexes  : 

                           Right                   Left 

Biceps                +2                        +2 

Triceps               +2                        +2

Supinator           +2                       +2

Knee                  +2                        +2

Ankle                 +2                        +2

Plantar          Flexor                     Flexor 

Based on the above findings, following investigations were sent : 

1.Hemogram 

2. Serum iron, ferritin 

3. Blood for MP - strip test 

4. PT , INR 

5. Stool bacterial culture and sensitivity 

6. Coombs test 

7. HbsAg 

8. Anti HCV antibodies

9. HIV 

10. ECG 

11. USG 

12. RFT 

13. LFT

14. Serum LDH 

15. Reticulocyte count 

16. Thyroid profile 

17. Vit B12 and folic acid 

Diagnosis : 

Megaloblastic anemia 

Bicytopenia with moderate spleenomegaly 

Indirect hyperbilirubinemia 

Treatment : 

1. Inj vitcofol 1000ug/im/od 

2. Tab Bplex forte OD 

3. Tab Pan 40mg / od

4. Tab Orofer-xt /Po/od 

5. Tab MVT OD 

6. Monitor BP, PR, RR

Patient is advised to take Vit B12 in following manner : 

July 1st to 7th/2020 : Inj vitcofol 1000ug IM 2cc for 7 days

July 14/ 2020 : Inj vitcofol 1000ug IM 2cc

July 21/2020 : Inj vitcofol 1000ug IM 2cc

July 28/2020 : Inj vitcofol 1000ug IM 2cc

Aug 4th 2020 : Inj vitcofol 1000ug IM 2cc

Sep 4th 2020 : Inj vitcofol 1000ug IM 2cc

Oct 4th 2020 : Inj vitcofol 1000ug IM 2cc

Nov 4th 2020 : Inj vitcofol 1000ug IM 2cc

Dec 4th 2020 : Inj vitcofol 1000ug IM 2cc