Long case

 A 40 yr old female with severe anaemia.

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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

CHIEF COMPLAINT:

A 40 yr old unmarried female came to OPD with the chief complaint of generalized weakness since 1yr
Decreased appetite since 1 yr
Bleeding per vaginal since 4 days.

HISTORY OF PRESENT ILLNESS:

Patient was asymptomatic 6 months back then there is  increased bleeding during her cycles. 
For 6months patient went to other private hospital where she was diagnosed with low Hb% and advised for blood transfusion which was not done and patient was not on any medication for anaemia.

HISTORY OF PAST ILLNESS:

No DM
No HTN
No thyroid
No epilepsy
No asthma

PERSONAL HISTORY:

Diet: Mixed
Appatite- Decreased since 2 years only 1 meal/ day 
Bowel and bladder movements: Normal
Sleep: Adequate
Addictions: None
Menstrual cycle: Patient attained menarche at the age of 14, since then cycles were regular, with normal flow initially.
4-5 days /month, no clots, dysmenorrhea. 

FAMILY HISTORY:

No similar complaints in the family

TREATMENT HISTORY:

Patient had never undergone any surgeries
She is not allergic to any drugs

GENERAL EXAMINATION:

Patient was coherent, conscious, non cooperative
thin built and malnourished.
Pallor- present 
Cynosis- no
Icterus- no
Clubbing- no
Edema- no
Vitals:
Temp- Afebrile
PR - 108bpm
BP-100/60 mmHg

LOCAL EXAMINATION:
Inspection:-
JVP raised

Palpation - thrills present
            
Auscultation - loud S1 S2  present  at pulmonary and tricuspid area , systolic murmer  present


SYSTEMIC EXAMINATION:

CVS- S1 AND S2 murmers present
CNS- patient was non Co operative.

DIAGNOSIS:

 Bicytopenia under evaluation

TREATMENT:

 1.inj TRANEXA 500MG IV stat
 2.inj pantop 40 mg iv/od
 3.inj zofer 4 mg iv/sos
 4. Plan for 1unit PRBC transfusion
 5. Monitor vitals 4th hrly
 6. I/o charting











INVESTIGATIONS: 
                               ECG on 07/02/2022

ECG ON 08/02/2022

-Abdomen

                                         2D Echo

Comments

  1. Goji Berries... yes... I tried those too.For my health conditions, Those sweet, red berries seemed to help, but only during the time when I consumed them. I don't want to take a drug for the rest of my life, so why would I want to take a natural supplement everyday for the rest of my life (although Goji berries are very tasty and are highly nourishing). To me this was not a cure either (and I'm LOOKING for the CURE).
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