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A 49 year old female patient elog

 SRINIJA KARNEKANTI

3rd semester , Roll no : 63

Under the guidance of Dr.Krupa.( Intern)

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.

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 a diagnosis and treatment plan.

★ CASE SCENARIO :

*A 49 yr old female , mother of 2 children apparently asymptomatic 13 yrs ago and then she noticed mass per anum with bleeding , went to hospital and diagnosed as haemorrhoids and got operated.

- Since 3 yrs she has history of muscle aches for which she is using NSAIDs.

- She has h/o fever 20 days back, got treated in the local hospital, and 

- Since 20 days she has generalized weakness.

- She also has h/o vomitings since 3 days, with food as content, non - projectile , non bilious.

★ HISTORY OF PRESENT ILLNSS :

- Urine output - Normal 

- No fatigability , pedal oedema , 

- SOB , facial fluffiness , yellowish discoloration of stools 

- H/O Haemorrhoids 13 years back - operated 

★ HISTORY OF PAST ILLNESS :

- No H/O Malena , blood / mucus in blood 

- N/K/C/O - DM -2 , HTN , epilepsy , TB , CVA , CAD 

★ TREATMENT HISTORY : 

- There is no usage of drugs as now 

★ PERSONAL HISTORY : 

-  Married 

- Occupation : Housewife

- Apettite : Lost 

- A vegetarian

- Bowels : regular

- Micturition : normal 

- No H/O known drug allergies or addictions 

★ FAMILY HISTORY :

- NAD 

★ MENSTRUAL HISTORY :

- 10/30 cycles , regular, no clots , lower backache 2-3 days 

Attained menopause 5 yrs back..

★ OBSTETRIC HISTORY :

- Gravida - 2

- Para - 2

- Family planning Methods used - IVD permanent sterilization 

★ BIRTH HISTORY :

- FTND 

- No H/O of  birth Asphyxia 

 ★ PHYSICAL EXAMINATION : 

A) GENERAL EXAMINATION

- H/O pallor , malnutrition 

- No H/O cyanosis , lymphadenopathy , icterus , clubbing of fingers or toes , oedema of feet , dehydration

- Temperature : Afebrile 

- BP : 130/80mmHg 

- PR : 68bpm

- RR : 14 cpm

- SPO2 : 98% at room air 

 SYSTEMIC EXAMINATION

B) CVS 

- Thrills : No 

- Cardiac sounds - S1 , S2 heard 

- Cardiac murmurs : No 

C) RS 

- Dyspnea : No 

- Wheeze : No 

- Position of Trachea : central 

- Breath Sounds : vesicular 

- Adventitious sounds : No 

D) ABDOMEN 

- Shape of abdomen : Scaphoid

- No tenderness , palpable mass 

- Hernial orrifices : Normal 

- No fluids , bruits 

- Liver and Spleen are not palpable

- Bowel sounds : yes 

- Genitals : Normal 

E) CNS 

- patient is conscious 

- speech is normal 

- No focal neurological defect is seen 

★ REFLEXES 

- Plantars : flexor 

★  CEREBRAL SIGNS :

- Finger - nose and Knee - Heel are in coordination 

★ INVESTIGATIONS : 


                       (  5/7/2021 )


* Vitamin B12 - 263 pg/ml 

* Iron -  76.5 microgram/dl 

* Total Iron Binding Capacity (TIBC) - 330 microgram/dl 

* Ferritin - 485.4 ng/ml 

* % Transferrin in saturation - 23.1%


                        ( 10/7/2021 ) 

* Bloop grouping - O +ve

* Vitamin B12 - 350 pg/ml 

* Iron - 59 microgram/dl 

* TIBC - 211 microgram / dl 

* % Transferrin saturation - 28% 

— ABG :

* PH - 7.29 {Normal : 7.35-7.45}

* Pco2 - 26.9mmHg                          {Normal - 35-45mmHg}

* Pco2 - 103mmHg                              {Normal - 85-95mmHg}

* Hco3 - 12.7 mmol/L 

* St. Hco3 - 14.8 mmol/L 

* BEB - -12.2 mmol/L 

* BEecf - -12.5 mmol/L

* Tco2 - 27.5vol

* O2 sat - 96.5% 

* O2 count - 11.9 vol%  

— HEMOGRAM 

* Hb - 6.5mg/dl 

* Total count - 5.200cell/cumm 

* Neutrophils - 65% 

* Lymphocytes - 25% 

* Eosinophils - 03% 

* Monocytes - 07% 

* Basophils -00%

* PCV - 18.9VOl% 

* MCV - 113.9fl 

* MCH - 39.2 pg 

* MCHC - 34.4% 

* RDW-CV - 14.3% 

* RDW-SD - 59.9fl 

* RBC COUNT - 1.66 millions/cumm 

* Platelet count - 2.15 lakhs /cumm 

* Smear 

- RBC - Amisopokilocytosis with microcytes , macrocytes , macro-ovalocytes and few tear drop cells 

- WBC - within normal limits 

- Platelets - Adequate in number and distribution 

- Hemoparasites - Not seen 

- impression - Dimorphic anaemia 

— Reticulocyte count - 1%


                       ( 11/7/2021 )


— SERUM ELECTROLYTES :

* Sodium - 135 mEq/L {Normal - 136-145}

* Potassium - 4.6mEq/L {Normal- 3.5-5.1}

* Chloride - 105 mEq/L {Normal - 98-107}

— SERUM CREATININE : 6.6 mg/dl 

         {Normal - 0.6-1.1}

— BLOOD UREA : 120mg /dl 

         { Normal : 12-42} 

— CUE 

* Colour - pale yellow 

* Appearance - clear 

* Reaction - Acidic 

* Specific gravity - 1.010 

* Albumin - nil 

* Sugar - nil 

* Bike salts - nil 

* Bile pigments - nil 

* Pus cell - 3-4

* Epithelial cells - 2-3 

* Red blood cells - nil 

* Crystals - nil 

* Casts - nil 

* Amorphous deposits - absent 

* Others - nil


                         ( 12/7/2021 )


— LFT 

* Total bilirubin - 0.42mg/dl                         { Normal : 0-1}

* Direct bilirubin - 0.16 mg /dl.         {Normal : 0.0 - 0.2} 

* SGOT - 13 IU/L { Normal : 0-31}

* SGPT - 10 IU/L { Normal : 0- 34 } 

* ALP - 93 IU/L { Normal : 42-98 }

* Total proteins - 7.0g/dl                   {Normal : 6.4-8.3} 

* Albumin - 3.0gm / dl {Normal: 3.5-5.2}

* A/G ratio - 0.75 

— SERUM CREATININE : 6.0 mg/dl 

— BLOOD UREA : 90 mg/dl 


                         ( 13/7/2021 )

— SERUM CALCIUM : 10.1mg/dl                        { Normal : 8.6-10.2 } 

— HBsAg-RAPID : Negative                                 { Kit name : Abon }

— Anti HCV Antibodies - RAPID :              Non-reactive { Kit name : Life Band}

— T3 : 1.08 ng/ml { Normal : 0.87-1.87 }

— T4 : 10.28 microgram/dl                                 { Normal : 6.32 - 12.23 } 

— TSH : 6.76 micro lu/ml                                       { Normal : 0.34-5.36 }

— HIV 1/2 Rapid Test : Non-reactive                    { Kit name : Abbott }


 

                     ECG ( 9/7/2021)





( 9/7/2021)




(10/7/2021)


(10/7/2021)


                  
(12/7/2021)



                          (11/7/2021)


                             ( 11/7/2021)


     


   SERUM PROTEIN ELECTROPHORESIS
                      




Bone marrow aspiration:- 16/07/2021









* Serum electrophoresis:-
 showed M- band in gamma region.

* Bone marrow aspiration:-
showed plasma cell dyscaria, probably multiple myeloma ( plasmacytosis 70%).
Mild to moderate supression of all cell lineages.

*2D echo
No significant abnormality.

*ECG
No significant changes.

*USG abdomen
Bilateral grade 2 RPD 

* Haemogram
* Hb:6.5
 TLC: 5200
 Platelet count: 2.15
                     Smear : dimorphic Anaemia. Reticulocyte count: 1%

*serum B12 and Iron profile
 are with in normal limits.

★ PROVISIONAL DIAGNOSIS :

- AKI ( PRE - RENAL ) on CKD 2° to Analgesic Nephropathy, associated with Acute Gastritis , Anaemia decreased Evaluation.

★ Rx 

- T. PAN 40mg /PO / OD
- oral fluids upto 1.5 - 2 lit / day
- Protein - x ( plant based ) 2 tablespoon   in 1 glass of  milk  
- Donot give IV fluids unless instructed
- T. ZOFER 4mg / PO / SOS
- Evaluate Anaemia start Iron Supplementation (oral ) after Gastritis ( (resolved )
- TAB NODOSIS  550 BD



★10/07/2021

- No fresh complaints 

 * VITALS :

 - O/E pt C/C/C
- Temperature : Afebrile
- PR : 110bpm
- BP : 110/70mmHg
- CVS : S1 , S2 heard
- CNS : NAD
- RS : Normal vesicular breath sounds
- P/A: soft

— Rx 

- oral fluids upto 1.5 - 2 lit / day 

- T. PAN 40mg /PO / OD 

-  T. ZOFER 4mg / PO /SOS 

- TAB NODOSIS  550 mg / PO/BD 

- Protein - x ( plant based ) 2 tablespoon   in 1 glass of  milk 

- I/O charting

- BP / PR / Temp  - 4th Hrly 

- Neb c Duoun 2 respules 8th hrly


★11/7/2021 

- c/o - nausea 

- O/E pt c/c/c 

- Temperature - Afebrile

- PR - 98bpm 

- BP -110/70mmHg

- CVS - S1, S2 (+) 

- CNS - NAD 

- RS - NVBS (+) 

- PA - soft 

— Rx 

- oral fluids upto 1.5 - 2 lit / day 

- Tab PAN-D  PO/OD ( 8AM)

- T. ZOFER 4mg / PO /SOS 

- TAB NODOSIS  550 mg / PO/BD 

- Protein - x ( plant based ) 2 tablespoon in 1 glass of milk 

- Inj ERYTHROPOIETIN 4000IVS/C weekly twice 

- BP / PR / Temp  - 4th Hrly  

- T. OROFER - XT PO/BD 

- Inj OPTINEORON 1 AMO IN 500ml NS IV/OD 

- IVF -NS  UO +30ml/hr 

          - RL 

- I/O - CHARTING 


★12/7/21

- No fresh complaints 

- O/E pt - c/c/c

- Temp - Afebrile

- PR - 106 bpm

- BP- 130/70 mmHg

- CVS - s1 & s2 heard

- CNS - NAD

- RS  - NVBS

- PA - soft

-I/o - 2000/1200


— Rx

-inj.optineuron 1 amp in 500ml NS IV/OD

-ivf. NS RL @ uo + 30 ml/hr

-inj. erytropoitin 4000 iv s/c weekly twice

-tab.pan-d po/od (8 am)

-tab.orofer-xt PO/BD

-tab.nodosis 500mg PO/BD

-protein- x powder 2 tsp in 1 glass of milk PO/TID

-tab. zofer 4mg PO/sos

-BP/PR/Temp - 4th hrly

- I/o - charting 


★13/7/2021

- C/o vomiting of 3 episodes , non - bilious , non- projectile food as content 

- no pain abdomen

-O/E pt - c/c/c

- temp - Afebrile

- PR- 106 bpm

- BP - 110/70 mmHg

- CVS - s1 s2 heard

- CNS- NAD

- RS - NVBS

- P/A - soft 

- I/O - 2500/170

— Rx

- Inj.optineuron 1 amp in 500ml NS SLOW/ IV/OD

-tab. pantop 40 mg RO/OD

-tab.nodosis 500mg PO/BD

-Protein- x powder 2 tsp in 1 glass of milk PO/TID

-I/o charting 

- T.OROFER  XT/OD


At outside hospital on 20/07/2021.












 At outside hospital:- On 23/07/2021 










                                             THANK YOU.....


 







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