A 49 yr old female with generalized weakness and vomitings
I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including, history, clinical findings, investigations, and come up with a diagnosis and treatment plan.
★ CASE SCENARIO :
*A 49 yr old female , mother of 2 children, who is a house wife, apparently asymptomatic 13 yrs ago and then she noticed mass per anum with bleeding , went to hospital and diagnosed as haemorrhoids and got operated.
- Since 3 yrs she has history of muscle aches, for which she is using NSAIDs.
- She has h/o fever 20 days back, got treated in the local hospital, and
- Since 20 days she has generalized weakness.
- She also has h/o vomitings since 3 days, with food as content, non - projectile , non bilious.
- Urine output - Normal
- No fatigability , pedal oedema ,
- No SOB , facial fluffiness , yellowish discoloration of stools
★ HISTORY OF PAST ILLNESS :
- N/K/C/O - DM -2 , HTN , epilepsy , TB , CVA , CAD
★ TREATMENT HISTORY :
- There is usage of NSAIDS for us 3 yrs.
★ PERSONAL HISTORY :
She is the 3rd Child in the family.
There are no significant events in the perinatal life.
Her childhood is normal.
She studied upto 10 th standard.
She got married at the age of 20, and she is a home maker.
Her age of menarche was 13 yrs, regular cycles, 5/30, with dysmenorrhoea, no clots.
She has 2 children 1 boy and 1 girl,
Both are normal vaginal delivaries.
No significant events in pregnancy, and post pregnancy.
Tubectomy done after 2 nd child birth.(25 yrs ago).
Her age of menopause was 46 ,
Before 6 months of her menopause , her cycles were 10/30, with dysmenorrhoea , no clots.
- Apettite : Lost
- A vegetarian
- Bowels : regular
- Micturition : normal
- No H/O known drug allergies or addictions
★ FAMILY HISTORY :
No significant family history
★ MENSTRUAL HISTORY :
- 10/30 cycles , regular, no clots , lower backache 2-3 days
Attained menopause 5 yrs back..
★ OBSTETRIC HISTORY :
- Gravida - 2
- Para - 2
- Family planning Methods used - IVD permanent sterilization
★ BIRTH HISTORY
- No H/O of birth Asphyxia
★ PHYSICAL EXAMINATION :
Restricted movement in the right wrist joint .
Not associated with pain.
There is no involvement of other joints.
A) GENERAL EXAMINATION
- pallor ++
- No H/O cyanosis , lymphadenopathy , icterus , clubbing of fingers or toes , oedema of feet , dehydration
- Temperature : Afebrile
- BP : 130/80mmHg
- PR : 68bpm
- RR : 14 cpm
- SPO2 : 98% at room air
SYSTEMIC EXAMINATION
B) CVS
- Thrills : No
- Cardiac sounds - S1 , S2 heard
- Cardiac murmurs : No
C) RS
- Dyspnea : No
- Wheeze : No
- Position of Trachea : central
- Breath Sounds : vesicular
- Adventitious sounds : No
D) ABDOMEN
- Shape of abdomen : Scaphoid
- No tenderness , palpable mass
- Hernial orrifices : Normal
- No fluids , bruits
- Liver and Spleen are not palpable
- Bowel sounds : yes
- Genitals : Normal
E) CNS
- patient is conscious
- speech is normal
- No focal neurological defect is seen
★ REFLEXES
- Plantars : flexor
★ CEREBRAL SIGNS :
- Finger - nose and Knee - Heel are in coordination
★ INVESTIGATIONS :
On 5/7/2021 (outside )
* Vitamin B12 - 263 pg/ml
* Iron - 76.5 microgram/dl
* Total Iron Binding Capacity (TIBC) - 330 microgram/dl
* Ferritin - 485.4 ng/ml
* % Transferrin in saturation - 23.1%
( 10/7/2021 )
* Bloop grouping - O +ve
* Vitamin B12 - 350 pg/ml
* Iron - 59 microgram/dl
* TIBC - 211 microgram / dl
* % Transferrin saturation - 28%
— ABG :
* PH - 7.29 {Normal : 7.35-7.45}
* Pco2 - 26.9mmHg {Normal - 35-45mmHg}
* Pco2 - 103mmHg {Normal - 85-95mmHg}
* Hco3 - 12.7 mmol/L
* St. Hco3 - 14.8 mmol/L
* BEB - -12.2 mmol/L
* BEecf - -12.5 mmol/L
* Tco2 - 27.5vol
* O2 sat - 96.5%
* O2 count - 11.9 vol%
— HEMOGRAM
* Hb - 6.5mg/dl
* Total count - 5.200cell/cumm
* Neutrophils - 65%
* Lymphocytes - 25%
* Eosinophils - 03%
* Monocytes - 07%
* Basophils -00%
* PCV - 18.9VOl%
* MCV - 113.9fl
* MCH - 39.2 pg
* MCHC - 34.4%
* RDW-CV - 14.3%
* RDW-SD - 59.9fl
* RBC COUNT - 1.66 millions/cumm
* Platelet count - 2.15 lakhs /cumm
* Smear
- RBC - Amisopokilocytosis with microcytes , macrocytes , macro-ovalocytes and few tear drop cells
- WBC - within normal limits
- Platelets - Adequate in number and distribution
- Hemoparasites - Not seen
- impression - Dimorphic anaemia
— Reticulocyte count - 1%
( 11/7/2021 )
- Vitamin B12-350(N)
- iron - 59(N)
_TIBC - 211 micro GM / dl(N- 215 -535
- % of transferrin saturation - 28%
— SERUM ELECTROLYTES :
* Sodium - 135 mEq/L {Normal - 136-145}
* Potassium - 4.6mEq/L {Normal- 3.5-5.1}
* Chloride - 105 mEq/L {Normal - 98-107}
— SERUM CREATININE : 6.6 mg/dl
{Normal - 0.6-1.1}
— BLOOD UREA : 120mg /dl
{ Normal : 12-42}
— CUE
* Colour - pale yellow
* Appearance - clear
* Reaction - Acidic
* Specific gravity - 1.010
* Albumin - nil
* Sugar - nil
* Bike salts - nil
* Bile pigments - nil
* Pus cell - 3-4
* Epithelial cells - 2-3
* Red blood cells - nil
* Crystals - nil
* Casts - nil
* Amorphous deposits - absent
* Others - nil
( 12/7/2021 )
— LFT
* Total bilirubin - 0.42mg/dl { Normal : 0-1}
* Direct bilirubin - 0.16 mg /dl. {Normal : 0.0 - 0.2}
* SGOT - 13 IU/L { Normal : 0-31}
* SGPT - 10 IU/L { Normal : 0- 34 }
* ALP - 93 IU/L { Normal : 42-98 }
* Total proteins - 7.0g/dl {Normal : 6.4-8.3}
* Albumin - 3.0gm / dl {Normal: 3.5-5.2}
* A/G ratio - 0.75
— SERUM CREATININE : 6.0 mg/dl
— BLOOD UREA : 90 mg/dl
13/07/2021
Serum calcium - 10.1( N-8.6- 10.2)
Thyroid function tests
T3- 1.08
T4-10.28
TSH-6.76( N-0.34-5.36)
ECG ( 9/7/2021)
— Rx
- oral fluids upto 1.5 - 2 lit / day
- T. PAN 40mg /PO / OD
- T. ZOFER 4mg / PO /SOS
- TAB NODOSIS 550 mg / PO/BD
- Protein - x ( plant based ) 2 tablespoon in 1 glass of milk
- I/O charting
- BP / PR / Temp - 4th Hrly
- Neb c Duoun 2 respules 8th hrly
★11/7/2021
- c/o - nausea
- O/E pt c/c/c
- Temperature - Afebrile
- PR - 98bpm
- BP -110/70mmHg
- CVS - S1, S2 (+)
- CNS - NAD
- RS - NVBS (+)
- PA - soft
— Rx
- oral fluids upto 1.5 - 2 lit / day
- Tab PAN-D PO/OD ( 8AM)
- T. ZOFER 4mg / PO /SOS
- TAB NODOSIS 550 mg / PO/BD
- Protein - x ( plant based ) 2 tablespoon in 1 glass of milk
- Inj ERYTHROPOIETIN 4000IVS/C weekly twice
- BP / PR / Temp - 4th Hrly
- T. OROFER - XT PO/BD
- Inj OPTINEORON 1 AMO IN 500ml NS IV/OD
- IVF -NS UO +30ml/hr
- RL
- I/O - CHARTING
★12/7/21
- No fresh complaints
- O/E pt - c/c/c
- Temp - Afebrile
- PR - 106 bpm
- BP- 130/70 mmHg
- CVS - s1 & s2 heard
- CNS - NAD
- RS - NVBS
- PA - soft
-I/o - 2000/1200
— Rx
-inj.optineuron 1 amp in 500ml NS IV/OD
-ivf. NS RL @ uo + 30 ml/hr
-inj. erytropoitin 4000 iv s/c weekly twice
-tab.pan-d po/od (8 am)
-tab.orofer-xt PO/BD
-tab.nodosis 500mg PO/BD
-protein- x powder 2 tsp in 1 glass of milk PO/TID
-tab. zofer 4mg PO/sos
-BP/PR/Temp - 4th hrly
- I/o - charting
★13/7/2021
-O/E pt - c/c/c
- temp - Afebrile
- PR- 106 bpm
- BP - 110/70 mmHg
- CVS - s1 s2 heard
- CNS- NAD
- RS - NVBS
- P/A - soft
- I/O - 2500/170
— Rx
- Inj.optineuron 1 amp in 500ml NS SLOW/ IV/OD
-tab. pantop 40 mg RO/OD
-tab.nodosis 500mg PO/BD
-Protein- x powder 2 tsp in 1 glass of milk PO/TID
-I/o charting
- T.OROFER XT/OD
14/07/2021
O/E pt - c/c/c
- temp - Afebrile
- PR- 120bpm
- BP - 110/70 mmHg
- CVS - s1 s2 heard
- CNS- NAD
- RS - NVBS
- P/A - soft
- I/O - 2500/170
— Rx
- Inj.optineuron 1 amp in 500ml NS SLOW/ IV/OD
-tab. pantop 40 mg RO/OD
-tab.nodosis 500mg PO/BD
-Protein- x powder 2 tsp in 1 glass of milk PO/TID
-I/o charting
- T.OROFER XT/OD
At outside hospital on 20/07/2021.
