This is an online E log book to discuss our patient's 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 available global online community of experts with an aim to solve those patient's clinical problems with 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 is welcome.
CASE PRESENTATION
A 50 year old Male patient who is a teacher by occupation came to OPD for review with C/O generalized weakness since 1 week. He is a k/c/o dimorphic anemia (IDA and MEGALOBLASTIC ANEMIA) , he was given INJ . Hydroxycobalamin 1000 mcg IM ( 10 doses), despite patient has no improvement in hemoglobin , reticulocyte count and platelets.
His previous case history details are as follows in the given e log link
https://spandanatippireddy.blogspot.com/2020/08/pancytopenia-under-evaluation.html
H/o constipation and painful defecation with blood streaks in stools on & of since 7 years
No H/o SOB
No H/o palpitations,vomitings,chest pain,cough,fever,melena,hemoptysis,hemetemesis , pain abdomen,yellowish discolourtion of urine ,bleeding per rectum.
PAST HISTORY:
No H/O DM,HTN,asthma,CKD,CVA,TB
PERSONAL HISTORY:
He has mixed diet, appetite normal, bladder normal , constipation since 7years and
Occasionally alocoholic (whisky 90ml)
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative and oriented to time, place and person
Pallor : Present
Hyperpigmentation of knuckles
No icterus,cyanosis,clubbing,lymphadenopathy ,koilonychia,pedal edema
VITALS:
Temperature-AFEBRILE
BP:120/70mmhg
PULSE:88bpm
RR:22cpm
Spo2:98% on RA
GRBS:126mg/dl
CVS:S1 S2 heard, no murmurs
RS: BAE clear, normal vesicular breath sounds heard,no added sounds
PER ABDOMEN:O/E soft, non tender, bowel sounds heard,umbilicus: inverted
CNS: higher mental functions: normal
Cranial nerves: intact
Motor system: intact
Sensory system: intact
INVESTIGATIONS:
ECG
