1801006053 - SHORT CASE

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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 diagnosis and treatment plan .

CHIEF COMPLAINTS:

   Pt. Presented to OPD with yellowish discolouration of eyes since 15 days, fever, abdominal discomfort and shortness of breath on exertion since 1 week. 1 episode of Blood in stools 2 days back

HOPI : 

Pt. Was apparently asymptomatic 3 yrs back then he developed fever for which he went to a hospital and on investigations he had hb of 4gm% so packed red blood cell transfusion was done and he was told by an attender that he had b12 deficiency for which he was given b12 Injections. His hb then improved to 12 gm% 

There were no similar complaints from past 3 years until 15 days back after which he developed yellowish discolouration of eyes, so he went to RMP and he was told he had jaundice for which he used a herbal medication for a week. After a week he developed high grade fever associated with chills and rigor, shortness of breath on exertion which was insidious in onset and gradually progressive and intermittent abdominal pain which was of squeezing type associated with nausea. No vomiting, hematemesis, malaena. 

2 days back, he had an episode of Blood in stools with a burning sensation while passing stools.

PAST HISTORY: 

Had Blood transfusion 3 yrs back.

Not a known case of DM/ HTN/ epilepsy/ asthma/ TB

PERSONAL HISTORY

Diet- veg 

Appetite- reduced.

Sleep- adequate. 

Bowel and bladder- bloody stools 

Addictions- beer ( 1 to 2 beer/ 2 weeks ) 

Micturition: Normal 

No allergies.

FAMILY HISTORY: 

No significant family history. 

GENERAL EXAMINATION:: 

PALLOR- present

Icterus- present 

Cyanosis: absent 

Clubbing - absent

Lymphadenopathy: absent 

Oedema- absent

VITALS :- 

Temperature 98.6f 

Pulse rate- 72 beats per minute

Respiratory rate- 20 breaths per minute.

B.P - 110/ 70mm hg

Spo2 - 99% at room air

GRBS - 92gm%

CVS:- S1 and S2 are heard, 

RS:- No dyspnoea, wheeze , NVBS+

P/A - no tenderness. 

CNS EXAMINATION: 

Pt. Was conscious coherent and co-operative  

Speech : Normal 

No signs of meningeal irritation.

Cranial nerves, Sensory system, motor system are normal.

INVESTIGATIONS:- 

Hb- 7.1 gm% 

Serum Iron - 78 micrograms per deciliter ( normal range- 60 to 170 micrograms per deciliter)

Serum ferritin- 

156 micrograms per deciliter 

Normal range- ( 24 to 336 micrograms per deciliter (mcg/dL)

TLC- 3100 (DECREASED)

MCV- 106.9 ( INCREASED)

MCH- 36.2( increased)

Rbc count- 2 million/ cumm ( DECREASED)

Normal range- 4 to 6 million/cumm 

RDW- 00 ( DECREASED) 

Smear shows:- 

Macrocytic normochromic with macrovalocytes, microcytes, tear drop cells , target cells fragmented forms

LDH- 3054 IU/L 

(Normal range- 230-460) 

LFT:- 

Elevated total bilurubin-2.68 mg/dl(0-1mg/dl)

Elevated direct bilurubin- 0.38mg/dl(0-0.02)

TOTAL PROTEINS ARE DECREASED-5.9gm/dl( (6.4-8.3gm/dl) 

RFT:-

Creatinine- 0.8mg/dl( 0.9-1.3mg/dl)

Provisional diagnosis:-

Megaloblastic anemia.

Treatment:-

Inject methylcobalamine