110 GOPAL KRISHNA RAMAVATH

 INTRODUCTION

This is online E log book to discuss our patient’s de-identified health data shared after taking his signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs

•A 34 year old male patient came to casualty with 

CHIEF COMPLAINTS:

•-> low grade fever [D7 of fever]

-> o/w vomitings [two episodes ] + generlized weakness 

--> H/o lung reactions for antibiotics

-> giddiness after getting up from sitting position no

HISTORY OF PRESENT ILLNESS:

-> bleeding gums ,`petechiae` , Melena, followed by discoloration of eyes ,not a/w pain abdomen, low backache,

H/o drug reaction to T.Acedon.p , itching, discoloration of fingers ,two days back decreased on taking R1 similar episodes in the past

-> one episode of giddiness on getting up from the bed not a/w LOC ,fall non rotational no ear pains , resolved spontaneously


HISTORY OF PAST ILLNESS :

-> kc/o alcoholic ( occasional) last being 1month back

->H/o TB, asthama,

    Similar H/o yellowish discdouation at the age of 25 

TREATMENT HISTORY:

Diabetes-No

Hypertention- No

CAD-NO

Asthma -No

Tuberculosis -No

Antibiotics - No

Hormones-No

Chemo/Radiation No

Blood Transfusion -  Yes, Details:SDP 

                                                              5yrs back

Surgeries - No

Other- No 


 PERSONAL HISTORY:

-> Married

->Occupation - farmer 

->Appetite - Normal

->Non-Vegeterian

->Bowels - Regular

->Micturition - Normal

->Known Allergies - Yes, details:T DCM antibiotics

  Habits/Addictions:

->Alcohol-Occasional

->Tobacco -No

->Drug use -No

->Betel nut - No

->Betel Leaf (Pan) - No

 

    GENERAL EXAMINATION:

1. Pallor-Yes       2. lcterus-Yes

3. Cyanosis-No.  

4. Clubbing of fingers/toes- No

5. Lymphadenopathy-No

6. Oedema of  feet- No

7. Malnutrition - No

8. Dehydration -Yes-Mild 

9. Temperature: Afebrele C/F

10. Pulse Rate : 98 /min

11.Respiration(Count for a full min)Rate /min

12.BP Lt 40/90 Arm mm/Hg:

13.SPO, at Room air...98% / at ____ltrs of O2

14.GRBS 133 mg%

SYSTEMIC EXAMINATION:

CVS:

-> S1 S2+

Respiratory system : 

->BAE+

Abdomen : 

-> soft ,non tender

Central Nervous System : 

-> no focal neurological deficits 

SEROLOGICAL INVESTIGATIONS:

Hb-6.2

TLC-4300

N-41

L-49

E-03

M-07

B-00

PLT-1.61

Clinical Urine Examination:

Pus cells-3 to 4

Epithelial cells-2 to 3

Reticulocyte count - 1.2%

Dengue - negative

Liver Function Test:

TB-1.92

DB-0.52

AST-58 

ALT-16

Alkaline Phosphate-75

Alb-3.9

A/G-2.24

Hamogram: -10/07/2021

Hb-5.9

TLC-4200

Neutrophils-35

Lymphocytes-56

PCV - 12.1

mcv-116.3

MCH-56.7

MCHC -48.8

RDW-CV-25.1

RBC Count-1.04


Hbs Ag-negative

Hiv - negative

Anti Hcv Ab - non reactive

LDH-1769

Cerum iron- 80

stool for occuli blood- negative

For furthur proper diagnosis the blood samples are send to microbiology dept.

The urine samples are send to pathology dept for CUE(complete urine examination)

The CUE did not have any major differences.....as the diagnosis is not yet conformed.....blood is send to get haemogram and complete blood picture


In the haemogram...... that the rbc count is too low......which suggest that it may be due to excess breakdown of rbc in liver.....so.....liver function test is suggested for final provisional diagnosis
Here are the reports of other tests 








HBsAg-RAPID: NEGATIVE

HIV1/2 RAPID TEST:Non Reactive

Anti HCV Antibodies-RAPID: Non Reactive

HEMOGRAM [10/07/2021]

HAEMOGLOBIN -5.9 gm/dl

TOTAL COUNT-4,200 cells/cumm

NEUTROPHILS -35%

LYMMPHOCYTES-56%

EOSINOPHILS-02%

MONOCYTES-07%

BASOPHILS -00%

PCV   -12.1 vol%

MCV  -116.3 fl

MCH -56.7 pg

MCHC -48.8%

RDW-CV - 25.1%

RDW-SD  - 66.1fl

RBC COUNT - 1.04 millions/cumm

PLATELET COUNT - 1.04 lakhs/cumm

HEMOGRAM [13/07/2021] 

HAEMOGLOBIN -6.5gm/dl

TOTAL COUNT-5,270 cells/cumm

NEUTROPHILS -40%

LYMMPHOCYTES-51%

EOSINOPHILS-01%

MONOCYTES-08%

BASOPHILS -00%

PCV   -13.3 vol%

MCV  -122.0 fl

MCH -59.6pg

MCHC -48.9%

RDW-CV - 27.7%

RDW-SD  - 91.5fl

RBC COUNT - 1.09 millions/cumm

PLATELET COUNT - 1.50 lakhs/cu mm

SERUM ELECTROLYTES:

Sodium-135 mEq/L

Pottasium-4.2 mEq/l

Chloride-95 mEq/l 

LDH:1,769 IU/L

SERUM IRON:80 ug/dl

SERUM CREATININE:

Serum creatinine-0.8 mg/dl

 DEPT.OF TRANSFUSION MEDICINE

Investigations; AHG [COOMBS TEST]

RESULTS      DCT - POSITIVE [4+]  

                       ICT -NEGATIVE

                       A/C- POSITIVE [4+]

BLOOD UREA:

Blood urea - 26 mg/dl

CLINICAL DIAGNOSIS

Mitral valve         :@ 

Tricuspid valve    : @

Pulmonary valve  :@

Aortic valve         : @

Right atrium       :@  

Right Ventricle   :@

 Left Atrium       :3.6 cms

Left Ventricle     :No RWMA

ESD :3.35 cms       EDD :4.94 cms    DPW : 1.0 cms     EF:60%

IVS  :1.0 cms

Aorta:3.15 cms

Intra cardiac masses : Nill 

Others : Nill

 DOPPLER STUDY:

Mitral Flow   : E>A

Aortic Flow   :1.35 m/sec

Pulmonary Flow :1.10

Tricuspid Flow    :Rvsp= 30 mmhHg

COLOUR FLOW MAPPING: Trivial  TR+/AR+ ; NO MR

CONCLUSION    : * NO RWMA ,NO AS/MS

                                 *Good LV systolic functions

                                *No Diastolic dysfunctions

                                *No PAH/PE

By all the tests done.

PROVISIONAL DIAGNOSIS:

->Pancytopenia 

->haemolytic anaemia

TREATMENT:

1) w/H    IV fluids.

2) Injection optinueron 1amp / IM/OD

3) Do not give PCM, Aceclofenac.

(H/o drung reaction).

4) I OROFER XT /PO /BD after giving sample for stool for oculty blood.

3) Strict Temp charting

ANAEMIA(secondary to haemolysis)


1) Injection Optinueron 1amp IM/OD

2) Tab Orofer -AT PO/BD

3) W/H IV FLUIDS -

4) Do not give pcm, Aceclofenac [H/o drug reaction]

5) BP PR TEMP -4th

6) TEMP CHARTING

7) TAB FEBREX PLUS/BD






THANK YOU.

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