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60 year old female with MEGALOBLASTIC ANEMIA

 

60 year old female with MEGALOBLASTIC ANEMIA

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients' problems through a series of inputs from an available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

G. Pravallika 

Roll no 41 

2019 batch 


Date of admission: 27/11/23


A 60 yr old female came casualty with the chief compliants of 

- Fever since 10 days 

-Generalised weakness since 4 days 

-Chest pain and tightness since 4 days

-Blood in stool since 3 days 

-Pedal edema since 3 days 


     


History of presenting illness:

-Patient was apparently asymptomatic 10 days back and  developed fever which intermittent high grade not associated with chills and rigor. Fever relieved on medication.

-Palpitations since since one week associated with chest pain and discomfort.

-There's excertional shortness of breath(.grade2or 3)

-No orthopnoea,no PND.

-Generalized weakness since 4dys.

-Blood in stools since 3 days.

-No h/o vomiting, loose stools ,pain abdomen and giddiness.


PAST HISTORY :

no h/o HTN,DM, epilepsy thyroid,asthma.


TREATMENT HISTORY

no h/o significant treatment history.


PERSONAL HISTORY 

Diet VEG now  ( stopped consumption of non veg from four yrs but not completely)

Appetite is  normal

Bowel and baldder movements regular

Sleep is adequate

No h/o allergies

Occasional consumption of toddy 


FAMILY HISTORY

not significant


MENSTRUAL HISTORY:

attained menopause 30 yrs ago


GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative

            pallor

Icterus


No cyanosis

No koilonychia

No lymphadenopathy



VITALS:

temperature:97 degrees F

Pulse rate: 96 beats per min

Respiratory rate: 2qcpm

Bp: 130/70 mm Hg


SYSTEMIC EXAMINATION:


CVS

S1S2 heard, S1 heard loud, systolic murmurs heard

Jvp raised


Respiratory system 

Trachea central

Normal vesicular breath sounds


 Per Abdomen 

Shape of the abdomen scaphoid

Non tender

No organomegaly


CNS 

no focal neurological deficits


Provisional diagnosis:


 PANCYTOPENIA secondary to megaloblastic Anemia/dengue /malaria



INVESTIGATIONS



CBP 

        27/11/23.     28/11/23

Hb.    4.2.                 6.0

Pcv   11.8.                17.3

TLC   6500.                5700

RBC  0.9.                  1.64

Esr. 1.5.                    1.20


RBS 125 on 27/11/23


Blood urea.   28

S.creatinine 0.6

S.Na+ 139

S.k+ 3.3

S.cl- 99


Clotting Profile

Pt tc 18

APTT TC  37

BT 2 mins

CT 4 mins


Bilirubin levels

T bilirubin 3.66

D bilirubin 0.81



Lft

SGOT 15

SGPT:80

ALP 63

Total proteins 7.1

AG ratio: 1.52


Lipid profile 

TG  227

LDL 62

VLDL 45.4


PERIPHERAL SMEAR:

Anisopoikilocytosis

With normocytes

Microcytes

Macrocytes teardrop cells 

Reticulocyte count 1.5%


ECG


Colordoppler



USG



TREATMENT

27/11/23

1) inj.pan 40mg 

2) 2 units PRBC transfusion 

3) need for sdp transfusion 

4) inj iron sucrose 200mg in 100ml NS iv OD

5) inj Vitcofol 1500 mg in 100ml IV OD


28/11/23

1) INJ iron sucrose 200mg in 100ml NS

2) inj Vitcofol 1500 mg in 100ml Ns IV OD

3)1unit  PRBC transfusion 

4)inj ceftriaxone 2gm iv OD

5) cap DOXYCYCLINE 100 mg iv OD

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