1801006024  - SHORT CASE 

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients' clinical problems with the 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 are welcome. 

 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, and investigations, and come up with a diagnosis and treatment plan.

CHIEF COMPLAINTS: 

Generalised weakness since 16 days

Shortness of breath since 16 days

Easy fatigability since 16 days 

HISTORY OF PRESENTING ILLNESS:

patient was apparently asymptomatic 16 days back he developed generalised weakness insidious in onset, gradually progressive

Shortness of breath of grade 2 

Easy fatigability present

No c/o fever, nausea, vomiting, chest pain, pain abdomen, blood in stools, loose stools, sweating

1 year back, then he developed jaundice and generalised weakness for which he took herbal medicines for 10 days and was resolved. 

PAST HISTORY: 

Not a k/c/o DM/HTN/TB/ Epilepsy/CVA/CAD/Asthma

PERSONAL HISTORY:

decreased appetite since 5-6 months

Takes vegetarian diet

Bowels and bladder habits are regular

Disturbed sleep 

Occassional alcohol drinker stopped 1 year back

FAMILY HISTORY: 

No significant family history

TREATMENT HISTORY: 

No significant history

GENERAL EXAMINATION: 

patient is conscious,cohorrent cooperative 

Pallor and icterus is present

No signs of cyanosis, clubbing, lymphadenopathy, pedal edema

Vitals:

Temp: afebrile

PR: 106 bpm

RR: 20 /min

BP: 130/90 mm hg

Systemic examination:

CVS: S1 S2 heard, No Murmur 

RS: Bilateral air entry present

CNS: No focal neurological deficit 

Per Abdomen : soft, non tender, no organomegaly

Bowel sounds heard

INVESTIGATIONS :

ECG  :

CHEST X RAY :

Diagnosis: Anemia secondary to vit b12 deficiency iron deficiency (dimorphic anemia)

 Treatment: 

Inj. VITCOFOL 1000mg/IM/OD

Dermatology opinion was taken on 9/3/23 i/v/o hyperpigmented scaly lesions over abdomen, groin, inner thighs, buttocks and legs

On 10/3/23

27 year old male came with c/o generalised weakness and shortness of breath since 10 days

S 

1 fever spike 

O

Pt is c/c/c 

BP-130/70 mmhg 

PR- 92bpm

Temp- 98.5F

CVS- S1,S2 heard, no murmurs 

RS- B/L Air entry present

P/A: soft, non-tender 

CNS: HMF intact, NFND   

A

Anemia Secondary to B-12 deficiency and Iron deficiency (Dimorphic) with Tinea Corporis ET Cruris +Statis Dermatitis

 

P: 

Inj. VITCOFOL 1000mg/IM/OD

LULIFIN CREAM L/A BD

LIQUID PARAFFIN L/A BD

TAB. TECZINE 5mg 

 Follow up on phone call -

Normal appetite 

Recent lab report done on 14th In Nalgonda

Hemoglobin:7.6gm/dl

Using medication - 

Inj. VITCOFOL 1000mg/IM/OD

LULIFIN CREAM L/A BD

LIQUID PARAFFIN L/A BD

TAB. TECZINE 5mg SOS