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
2D Echo
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