A 60F with Megaloblastic Anemia

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

This E blog also reflects my patient centred online learning portfolio and your valuable inputs on the comment box is 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, investigations and come up with diagnosis and treatment. 


DOA - 27/11/2023

CHIEF COMPLAINTS:

Fever since 1 week

Palpitations since 1 week 

Generalised weakness since 4 days 

Blood in stools since 3 days 

Chest pain and tightness since 4 days


HISTORY OF PRESENTING ILLNESS 

The patient was apparently asymptomatic 1 week ago and then she developed fever which is sudden in onset, high grade, associated with chills and rigors, relieved temporarily on medication. 

Palpitations are present since 1 week which are regular and associated with chest discomfort 

There is h/o shortness of breath on exertion which is progressive (grade 2 to grade 3). No orthopnea, or PND.

There is associated generalised weakness since 4 days and blood in stools since 3 days. 

There is no h/o vomitings, loose stools, pain abdomen, giddiness.


PAST HISTORY

N/k/c/o DM, HTN, Asthma, TB, Epilepsy, CAD, CVA

There is h/o tubectomy 

PERSONAL HISTORY 


Diet mixed 


Appetite normal


Sleep adequate


Bowel movement- Constipation present, Bladder regular 


Addictions - None


GENERAL EXAMINATION 


Pt is conscious, coherent and cooperative and well oriented to time, place and person. 

No cyanosis, clubbing, lymphadenopathy and edema

Pallor present 

Icterus present 



.



Vitals on admission - 

Temp - 98F 

BP - 130/70 mm hg 

PR - 98bpm 

RR- 22cpm 

Grbs - 131mg/dl 

SpO2 - 90% @ RA 

SYSTEMIC EXAMINATION 


CVS - S1 loud, S2 heard, JVP raised, systolic murmur present 

RS - trachea - central , bilateral air entry +, NVBS heard, no added sounds 

PER ABDOMEN - soft, non tender, hepatomegaly present, bowel sounds heard 

CNS - NFND




INVESTIGATIONS

 


PROVISIONAL DIAGNOSIS 


Megaloblastic Anemia 


TREATMENT 


27/11/23- 


1 unit PRBC Transfusion 


Inj Pan 40mg IV OD


Inj Iron sucrose 200mg in 100ml NS IV OD


Inj Vitcofol 1500mg in 100ml NS IV OD


Strict I/O charting, monitor vitals, inform sos 


28/11/23-


1 unit PRBC transfusion 


Inj Ceftriaxone 2g IV BD


Cap Doxycycline 100mg PO BD


Inj Pan 40mg IV OD


Inj Iron sucrose 200mg in 100ml NS IV OD


Inj Vitcofol 1500mg in 100ml NS IV OD


Strict I/O charting, monitor vitals, inform sos 




OSCE 


What are the causes of tear drop cells/dacrocytes in the peripheral smear?


Seen in - 


Iron deficiency, Vitamin B12 deficiency, Myelophthisic anemia , Myelofibrosis. They can also occur as an artefact in blood smear preparation with all pointed ends facing one side 


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