General medicine monthly online assessment



                                    A CASE OF ANEMIA
This Eblog has been created under the guidance of Dr MADHUMITHA. BUDIGAM

 The case is :
A 20 year old female patient came to OPD  , she is a student. 
Her chief complaints are:
Yellow discoloration of sclera
Burning sensation b/w lowerlimbs
Weakness
Loss of appetite
Weight loss
All these complaints are since 6months 

HOPI:

 The patient had all the above complaints since 6months and she was asymptomatic 6months ago. She started taking herbal medicine when she developed yellowish discoloration for 2days and stopped . 
History of Burning sensation b/w lower limbs is seen over a period of time. 
Weakness and weight loss around 10 to12 kgs is also seen. Patient also gives history of passing dark colored stools sometimes. 
Past history
No h/o fever 
No h/o drug intake 
No h/o hematuria
No h/o rashes 
2 days back she gives h/o visiting local hospital and the tests done are 
Total billirubin- 7g/dl
Direct bilirubin- 3g/dl
Hemoglobin- 4g/dl
TLC- 3300
Platelets - 1.3 L / cumm
GENERAL EXAMINATION:-
Patient is 
Conscious
Coherent
Cooperative
Pallor is present
Icterus is present

SYSTEMIC EXAMINATION:-

Vitals- PR =88bpm
            BP= 105/60 mmhg
            RR= 14cpm
            TEMP= afebrile 
            SPO2= 100% at room air.
CVS:-
S1, S2 heard 
Palpable P2
Parasternal heave is present. 

RESPIRATORY SYSTEM :-
BAE+
NVBS heard

PER ABDOMEN :-
Shape of the abdomen is scaphoid. 
Tenderness is present in Right hypochondrium. 
Liver and spleen are not palpable. 
Bowel sounds are heard.

CNS :-
Patient is conscious. 
Speech is normal.
No signs of meningeal irritation. 
Reflexes are normal.

PROVISIONAL DIAGNOSIS  :-
Anemia with indirect hyperbilirubinemia under evaluation.

INVESTIGATIONS:-

HEMOGRAM 


CUE


PERIPHERAL SMEAR


MALARIA PARASITE


ESR


RETICULOCYTE COUNT


USG ABDOMEN 


ECG

CXR





TREATMENT :-
1)Date- 30.6.2021
• Inj. Pantop 40mg IV/OD.
• Monitor vitals
• Strict I/O charting.

2) Date - 1.7.2021
•Inj. Pan 40mg IV/OD
• Tab. Folic acid 5mg PO/OD.
• Tab. Zincovit PO/OD.
• Inj. Vitcofol 1amp IM/OD.

3) Date - 2.7.2021
•Inj. Pan 40mg IV/OD
• Tab. Folic acid 5mg PO/OD.
• Tab. Zincovit PO/OD.
• Inj. Vitcofol 1amp IM/OD

DISCHARGE TEMPLATE:- 
1)Date- 30.6.2021
• Inj. Pantop 40mg IV/OD.
• Monitor vitals
• Strict I/O charting.

2) Date - 1.7.2021
•Inj. Pan 40mg IV/OD
• Tab. Folic acid 5mg PO/OD.
• Tab. Zincovit PO/OD.
• Inj. Vitcofol 1amp IM/OD.

3) Date - 2.7.2021
•Inj. Pan 40mg IV/OD
• Tab. Folic acid 5mg PO/OD.
• Tab. Zincovit PO/OD.
• Inj. Vitcofol 1amp IM/OD.

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