60f with fever ( prefinal)

This is an a online e log book to discuss our patient 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.
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

Date of admission: 27/11/23

A 60 yr old female came casualty with the chief compliants of 
       FEVER SINCE 10DAYS
      PEDAL EDEMA SINCE 3 DAYS
     GENERALISED WEAKNESS SINCE 4 DAYS
     BLOOD IN STOOLS SINCE 3DAYS
    CHEST PAIN AND TIGHTNESS SINCE 4DAYS

HOPI:
patient was apparently asymptomatic 10 days back and  developed fever which intermittent high grade not associated with chills and rigor.fever relieved on medication.
palpitations since since one week associated with chest pain and discomfort.
There's excertional shortness of breath(.grade2or 3)
No orthopnoea,no PND.
Generalized weakness since 4dys.
Blood in stools since 3 days.
No h/o vomiting, loose stools ,pain abdomen and giddiness.

PAST HISTORY :
no h/o HTN,DM, epilepsy thyroid,asthma.

TREATMENT HISTORY
no h/o significant treatment history.

PERSONAL HISTORY 
Diet VEG now  ( stopped consumption of non veg from four yrs but not completely)
Appetite is  normal
Bowel and baldder movements regular
Sleep is adequate
No h/o allergies
Occasional consumption of toddy 

FAMILY HISTORY
not significant

MENSTRUAL HISTORY:
attained menopause at 30 yrs ago

GENERAL EXAMINATION:
pt is conscious coherent and cooperative
            pallor
.               Icterus
No cyanosis
No koilonochia.
No lymphadenopathy
VITALS:
temperature:96.8
Pulse rate: 98
Respiratory rate: 22cpm
Bp: 130/70

SYSTEMIC EXAMINATION:

CVS
S1S2 heard, S1 heard loud, systolic murmurs heard
Jvp raised

Respiratory system 
Trachea central
Normal vesicular breath sounds

 Per Abdomen 
Shape of the abdomen scaphoid
Non tender
No organomegaly

CNS 
no focal neurological deficits

Provisional diagnosis:

 PANCYTOPENIA secondary to megaloblastic Anemia/dengue /malaria


INVESTIGATIONS


CBP 
        27/11/23.     28/11/23
Hb.    4.2.                 6.0
Pcv   11.8.                17.3
TLC   6500.                5700
RBC  0.9.                  1.64
Esr. 1.5.                    1.20

RBS 125 on 27/11/23

Blood urea.   28
S.creatinine 0.6
S.Na+ 139
S.k+ 3.3
S.cl- 99

Clotting Profile
Pt tc 18
APTT TC  37
BT 2 mins
CT 4 mins

Bilirubin levels
T bilirubin 3.66
D bilirubin 0.81


Lft
SGOT 15
SGPT:80
ALP 63
Total proteins 7.1
AG ratio: 1.52

Lipid profile 
TG  227
LDL 62
VLDL 45.4

Ns1 antigen: negative

PERIPHERAL SMEAR:
Anisopoikilocytosis
With normocytes
Microcytes
Macrocytes teardrop cells 
Reticulocyte count 1.5%

ECG
Colordoppler
USG

TREATMENT
27/11/23
1) inj.pan 40mg 
2) 2 units PRBC transfusion 
3) need for sdp transfusion 
4) inj iron sucrose 200mg in 100ml NS iv OD
5) inj Vitcofol 1500 mg in 100ml IV OD

28/11/23
1) INJ iron sucrose 200mg in 100ml NS
2) inj Vitcofol 1500 mg in 100ml Ns IV OD
3)1unit  PRBC transfusion 
4)inj ceftriaxone 2gm iv OD
5) cap DOXYCYCLINE 100 mg iv OD







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