45 year old female

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

Name: G Sai Manogna

Roll no: 41

I've 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.

Following is the view of my case :

CASE PRESENTATION:

A 45 year old female who is a resident of miryalaguda has come to the casualty with the chief complaints of 

  • Increased bleeding per vaginum since 5 days
  • SOB since 5 days
  • Palpitations since 5 days
  • Pain abdomen since 5 days
History of Presenting illness:
Patient was apparently asymptomatic 5 days ago then she had her menstrual cycle started which was associated with increased bleeding per vaginum for 3 days during the cycle
on first 2 days she changed 10-12 pads per day from then 1-2 pads per day
No h/o bleeding manifestations from other sites
With the increased bleeding per vaginum she also developed shortness of breath which is Grade 2
Orthopnea
PND
Palpitations +
It was associated with Pain abdomen which is insidious in onset and gradually progressive (Site?)
No h/o burning micturition
No h/o any white discharge per vaginum
No h/o pain radiating to other sites
No c/o black coloured stools
No history of chest pain

No facial puffiness
No history of decreased urine output

Past History:
No h/o similar complaints in the past
Known case of hypertension since 2 months and is not regular (Medication unknown)
Not a known case of DM, TB, Asthma, Epilepsy, CVA, CAD
No history of any blood transfusions
No h/o any previous surgeries
No known allergies

Personal history:
Diet- Mixed
Appetite- Good
Bowel and bladder movements- Regular
Sleep- Adequate
Addictions- None

Family history:
No significant family history
No family history of Hypertension, Diabetes, TB, Asthma, Seizures

General Physical Examination:
Done after obtaining consent, in the presence of attendant with adequate exposure
Patient is conscious, coherent, cooperative
well oriented to time, place and person
well nourished and moderately built

Pallor- ++
Icterus- Absent
Cyanosis- Absent
Clubbing- Absent
Lymphadenopathy- Absent
Edema- Absent

Vitals
Temperature- Afebrile
Blood pressure- 120/80 mm of Hg
Pulse rate- 78 bpm
Respiratory rate- 18 cpm
SpO2- 98% at room air

Systemic Examination:

Cardiovascular system:
S1 and S2 sounds are heard
No abnormal murmers

Respiratory system:
Bilateral air entry is present
Trachea is central
Normal vesicular breath sounds are heard
Dyspnoea is present
No adventitious sounds are heard

Abdominal Examination:
Shape of Abdomen is distended
Soft and non tender
Bowel sounds are heard
No palpable mass
Hernial orifices are normal
No organomegaly

Central Nervous System:
No focal neurological deficits

Provisional diagnosis:
Dimorphic anaemia (Iron and Vit B12 deficinecy) with AUB (Fibroid uterus) with left adnexal mass with K/C/O HTN sincr 2 months
2 PRBC transfusion done

Temperature charting



Investigations:
Day 1 (26/11/22)
Hemogram
Hb- 4.9 
TC- 8200
Neutrophils- 70
Lymphocytes- 25
Eosinophils- 0
Monocytes- 05
Basophils- 0
PCV- 17.1
MCV- 63.8
MCH- 18.3
MCHC- 28.7
RDW-CV- 19.3
RDW-SD- 45.1
RBC Count- 2.68
Platelet count- 5.44
Smear
RBC- Microcytic hypochromic
WBC- With in normal limits
Platelets- Count increase on smear
Hemoparasites- No hemoparasites seen
Impression- Microcytic hypochromic anaemia with thrombocytosis

Blood grouping and RH typing
O NEGATIVE

Blood sugar random
RBS- 116 mg/dL

Blood urea
Blood urea- 19 mg/dL

Complete Urine Examination
Colour- Pale yellow
Appearance- Clear
Reaction- Acidic
SP. gravity- 1.010
Albumin- Nil
Sugar- Nil
Bile salts- Nil
Bile pigments- Nil
Pus cells- 2-3
Epithelial cells- 2-4
Red blood cells- Nil
Crystals- Nil
Casts- Nil
Amorphous deposits- Absent
Others- Nil

ESR
ESR- 136 

HBsAg- RAPID
HBsAg RAPID- Negative

Anti HCV Antibodies- RAPID
Anti HCV Antibodies- RAPID- Negative

HIV 1/2 Rapid Test
HIV 1/2 Rapid Test- Non reactive

Liver Function tests
Total bilirubin- 0.53
Direct bilirubin- 0.18
SGOT(AST)- 11
SGPT(ALT)- 15
ALP- 116
Total Proteins- 7.1
Albumin- 3.8
A/G ratio- 1.15

Reticulocyte count
Reticulocyte count- 0.7%

Serum creatinine
Serum creatinine- 0.9 mg/dL

Serum electrolytes
Sodium- 138 mEq/L
Potassium- 3.7 mEq/L
Chloride- 104 mEq/L
Calcium ionized- 0.84 mmol/L

Serum Iron
Serum Iron- 32

Ferritin
Ferritin- 2.4

APTT
APTT- 37 sec

PT-INR
PT- 19 sec
INR- 1.4

Day 2 (26/11/22)
Hemogram

Hb- 6.7
TC- 9100
Neutrophils- 72
Lymphocytes- 20
Eosinophils- 1
Monocytes- 07
Basophils- 0
PCV- 22.3
MCV- 68.8
MCH- 20.7
MCHC- 30.0
RDW-CV- 22.3
RDW-SD- 55.6
RBC Count- 3.24
Platelet count- 4.8
Smear
RBC- Anisopoikilocytosis microcytes pencil forms tear drops macrocytes and normocytes macroovalocytes with in normal limits
WBC- With in normal limits
Platelets- Adequate platelet clumps are present
Hemoparasites- No hemoparasites seen
Impression- Dimorphic anemia

Peripheral Smear
Peripheral smear
RBC- Anisopoikilocytosis with microcytes macroovalocytes and pencilforms tear drops and macrocytes and normocytes
WBC- With in normal limits
Platelet- Adequate (Platelet clumps are present)

Day 3 (27/11/22)
Hemogram

Hb- 7.1
TC- 8100
Neutrophils- 60
Lymphocytes- 22
Eosinophils- 6
Monocytes- 12
Basophils- 0
PCV- 23.7
MCV- 69.1
MCH- 20.7
MCHC- 30.0
RDW-CV- 22.4
RDW-SD- 55.6
RBC Count- 3.43
Platelet count- 5.06
Smear
RBC- Anisopoikilocytosis microcytes pencil forms tear drops macrocytes and normocytes macroovalocytes with in normal limits
WBC- With in normal limits
Platelets- Adequate in number and distribution
Hemoparasites- No hemoparasites seen
Impression- Dimorphic anemia


Liver Function tests
Total bilirubin- 0.62
Direct bilirubin- 0.15
SGOT(AST)- 17
SGPT(ALT)- 11
ALP- 114
Total Proteins- 7.5
Albumin- 3.9
A/G ratio- 1.10


ECG


Chest Xray PA view


2D Echo


USG abdomen


SOAP Notes
Day 1 (25/11/22)
S
SOB + 
Palpitations +

O
Patient is conscious, coherent, cooperative
Temp - 98.6 F
BP- 150/80 mmHg'
PR- 92 bpm
RR- 22 cpm
SPO2- 100% on RA

CVS- S1, S2 +, No murmurs heard
RS- BLAE +, No added sounds
P/A- Soft, non tender
HMF- Intact +

A
Anemia under evaluation secondary to menorrhagia (?AUB)

P
1. Inj. Tranexamic acid 500 mg IV/SOS
2. Plan for 1 PRBC transfusion
3. Tab. TELMA 20 mg/ PO/BD (1-x-x)

Day 2 (26/11/22)
S
SOB + 
Palpitations +

O
Patient is conscious, coherent, cooperative
Temp - 98.6 F
BP- 110/80 mmHg'
PR- 95 bpm
RR- 22 cpm
SPO2- 99% on RA
GRBS- 100 mg/dL
CVS- S1, S2 +, No murmurs heard
RS- BLAE +, No added sounds
P/A- Soft, non tender
HMF- Intact +

A
Anemia under evaluation secondary to menorrhagia (?AUB)

P
1. Inj. Tranexamic acid 500 mg IV/SOS
2. Tab. MVT PO/BD
3. Inj. Vitcofol 1500 mg/ IM/ OD
4. Monitor vitals 4th hourly

Day 3 (27/11/22)
S
SOB -
Palpitations -

O
Patient is conscious, coherent, cooperative
Temp - 98.6 F
BP- 140/90 mmHg'
PR- 86 bpm
RR- 23 cpm
SPO2- 99% on RA
GRBS- 124 mg/dL
CVS- S1, S2 +, No murmurs heard
RS- BLAE +, No added sounds
P/A- Soft, non tender
HMF- Intact +

A
Anemia under evaluation secondary to menorrhagia (?AUB)

P
1. Inj. Vitcofol 1500 mg + 5 mg / IM/ OD
2. Tab. Levogen 150 mg/ PO/ OD
3. Tab. TELMA 20 mg/ PO/ SOS
4. Plan for 1 PRBC transfusion today
5. Monitor vitals 4th hourly

Medical ward
Day 4 (28/11/22)

Patient is conscious, coherent, cooperative
Temp - 98.4 F
BP- 120/90 mmHg'
PR- 78 bpm
RR- 21 cpm
SPO2- 99% on RA
CVS- S1, S2 +, No murmurs heard
RS- BLAE +, No added sounds
P/A- Soft, non tender
HMF- Intact +
2 PRBC transfusion done

Today's Haemogram
Hb- 7.7 gm/dL
TC- 16,800 cells/cumm
PLT- 5.13 lakhs/cumm

A
Dimorphic anemia (Iron + Vit B12 deficinecy) with AUB (Fibroid uterus) with left adnexal mass 
With K/C/O HTN since 2 months

P
Rx
1. Inj. Vitcofol 1500 meq + 5 mg / IM/ OD
2. Tab. Levogen 150 mg/ PO/ OD
3. Tab. TELMA 20 mg/ PO/ SOS
4. Monitor vitals 4th hourly

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