KIMS HOSPITALS Narketpally 

Hello all , I’m an intern of 2015 batch , this is a case history of one of our patients who got admitted . This is to complete my log book as a part of internship duties .

Age/Gender: 60 year  female
Case Report 
2017
 the patient Low grade fever intermittent, on and off, so she went to hospital and on investigation she had anemia with jaundice, and conservative treatment was given . She had yellowish discolouration of eyes and high coloured urine 
No h/o pain abdomen , cough , abdominal distension 
2020 
C/ o loss of appatite since 20 days 
Generalised weakness since 1 month 
Nausea + ve 
Fever low grade intermittent  , on and off since 1 month , yellowish discolouration of eye since 3 days ,grade 2 SOB since 1 month 
No h/ o Chest pain , cough, orthopnea , PND, palpitations , pedal oedema.
PAST HISTORY 
HTN Since 5 years  and on ramipril 2.5 mg OD 
ON EXAMINATION 
Pt c/ c
Temperature 98.6  F 
Pule 87 bpm
BP 120/ 60 mmhg 
Spo2 99%
Cvs :S1 S2 heard ,no murmurs 
Respi: BEA + ve , NVBS heard 
p/ A : soft , non tender 
CNS : HMF intact
           Speech normal
           Sensory system N
           Motor system N 
INVESTIGATIONS
Haemogram
Hb :5.6 gm/ dl 
TLC :2400 cells / cumm
Lymphocytes:57
Plt- 40,000 cells /cumm
Smear :
RBC : hypochromasia with anisopoikilocytosis comprising macrocytes , macroovalocytes,ocational tear drop cells ,normocytes ,schistocytes and nucleated RBC 0-1/100wbc 
WBC : leukopenia with lymphocytes and hypersegmented neutrophills 
PLATELETS 
thrombocytopenia 
IMPRESSION
Pancytopenia for evaluation , suggestive of megaloblastic anemia adviced b12 and folic acid levels 
RETICULOCYTE COUNT 3%
CUE
pus cells 4-5 
RBC nil 
Sugar nil 
Albumin +
LFT:
TB - 4.96  mg/ dl 
DB - 2.35 mg/ dl 
SGOT - 62
SGPT- 15
Alp - 103 
TP-6.3
Albumin -4.5
A/G- 2.6
RFT
Urea -21
Creatinine-0.6
UA - 4.8 
Ca-10.6
PO4 -3.8
Na - 142
K-3.6
Cl-104
LDH  1220  IU /L
 Diagnosis:pancytopenia ?secondary to b12 deficiency with conjugate hyper bilirubinemia  with hypertension 
Treatment
1. tab PAN 40 mg OD
2. Monitor BP ,pR,spo2
3. Inj .Vitcofol 2cc/IM/od
4 Tab orofer 
  1. Tab Ramipril 2.5 mg /od
Procedures Learnt
  1. acetic tap
on a portal hypertension patient with alcoholic liver disease. We drained 2 lit of straw coloured clear ,fluid in order to relieve the dyspnoea of patient.after which the patient felt subjectively well .
Topic learnt 
Hypertrophic cardiomyopathy 
1)It is the most common cause of sudden cardiac death in young athletes 
2)It equally prevalent in both males and females 
Symptoms include 
Palpitations 
Dizzyness 
Syncope 
Angina 
Most of the the patients are asymptotic and go undiagnosed 
Treatment 
Beta blockers 

Diuretics

Comments

  1. caregiver7careseeker12 May 2020 at 20:30

    Thanks Advitha.

    Well done.

    Can you remove the hospital identifier also from your log book as an extra precaution to protect patient confidentiality as per the consent forms available in our medicine office as well as here https://medicinedepartment.blogspot.com/2020/05/informed-patient-consent-and.html?m=1

    Please check the comments in the other intern's log book comment box here as a lot of those comments are generalizable https://vaish7.blogspot.com/2020/05/medicine-intern.html?m=1

    Some specific questions and comments below:

    What was the reason for pancytopenia in your patient?

    Why was her LDH so high?

    How do you plan to follow up this patient? What happens if she doesn't respond to your hematinic therapy? What would you do next?

    What happened next to your patient after he felt relieved with your ascitic tap? How would you follow him up on phone?

    Please share the video of the HOCM discussion session

    ReplyDelete
  2. monika12 May 2020 at 21:24

    Written well.would like to know durationeduration of her fever,was any over the counter drug taken for same.
    Her diet history ?
    Was any echo done for her?

    ReplyDelete
  3. Advytha Reddy12 May 2020 at 22:25

    Low grade intermittent fever on and off for one month. Paracetamol 650 mg tablet taken when ever required

    ReplyDelete
  4. Dr Keerthi Sree Reddy Endoori_GastroDoc12 May 2020 at 23:22

    Nicely blogged advaita.
    Any history of intake of herbal medication since 2017?
    Description of patients stools?
    Are the patients reflexes Normal?
    And JVP?

    ReplyDelete
  5. Dr vinuthna12 May 2020 at 23:53

    Good blog advaitha

    ReplyDelete
  6. Dr. Deepak13 May 2020 at 00:33

    Very nice presentation advytha.what is your further plan of action

    ReplyDelete
  7. Dr.Vinod Raman13 May 2020 at 01:04

    Great job Advaitha..try to add some notes on differential diagnosis and how you eliminated those probable differentials.

    ReplyDelete

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