SHORT CASE - A 45 year old male came to the OPD with the chief complaints of SOB ,tingling sensation and dark stools.

 SHORT CASE : FINAL PRACTICAL

MEDICAL CASE

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient 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 comments in comment box are most welcomed 

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

Viharika Vupputuri

1701006197

June 15,2022.

CASE PRESENTATION

A 45 year old male came to the OPD with chief complaints of 

Shortness of breath on exertion since 2 months.

Tingling sensation of limbs since 2 months.

Dark coloured stools since 3 days.

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 2 months back then he developed shortness of breath which is insidious in onset grade 2 gradually progressed to grade 3 .

Patient complains of tingling sensation in legs since 2 months .

Patient also complains of dark coloured stools since 3 days.

PAST HISTORY

No similar complaints in the past. Not a known case of hypertension , diabetes , asthma , epilepsy, TB.

Patient had an episode of involuntary movements with drooling of saliva and uprolling of eyeballs 20 years back and was admitted in the hospital and diagnosed as epilepsy and took medication. Later 2-3 episode of seizures were seen within 15 days. Then he had seizure free period.

PERSONAL HISTORY

Diet - Mixed

Appetite - Normal

Bowel and bladder habits - passage of dark coloured stools 3 days back , one episode per day

Addictions - Used to consume alcohol daily since 12 years about 90 ml everyday.

Alcohol abstinence since 2 months

No allergies  

FAMILY HISTORY

Insignificant

GENERAL EXAMINATION

Patient is conscious, coherent and cooperative and well built and moderately nourished. 

Patient is examined in a well lit room.

Pallor - present 

No signs of icterus, clubbing, cyanosis, lymphadenopathy and edema.

VITALS- 

Temperature- afebrile

BP- 110/80

RR- 16cpm

PR - 80bpm

SYSTEMIC EXAMINATION 

CVS 

S1 ,S2 heard 

No murmurs

RS  - NVBS heard 

CNS - normal

Per abdomen 

Soft , non tender 

No organomegaly.

INVESTIGATIONS

10/6/22:

CBP:

Hb : 3.2 g/dl

TLC: 3,400 cells/cumm 

Neutrophils: 42

Lymphocytes: 56

Eosinophils: 0

Monocytes: 02

Basophils: 0

PCV : 9.2

MCV: 117.9

MCH: 42

MCHC: 34.8

RDW-CV: 24.2

RBC: 0.78 

Platelets: 68,000

ESR: 40

Reticulocyte count: 0.5

LFT:

TB: 2.69

DB: 0.70

ALT: 14

AST:51

ALP: 115

TP: 5.8

Albumin: 3.6

A/G: 1.69

RFT:

Blood urea: 16

Serum Creatinine: 0.8

Serum Uric acid: 7.8

Serum Electrolytes:

Serum Calcium: 8.9

Serum Phosphorus: 3.9

Na+: 133

Cl: 107

K+: 3.8

RBS: 104

LIPID PROFILE:

Total cholesterol: 90

Triglycerides: 116

HDL: 24

LDL: 49

VLDL: 23

12/6/22:

Hb: 2.8 g%

TLC: 2380

Neutrophils : 36

Lymphocytes: 60

Eosinophils:0

Monocytes: 4

Basophils: 0

PCV: 8

MCV: 115.8

MCH: 39.8

MCHC: 34.3

RDW-CV: 33.5

RBC: 0.69

PLT-  72,000

Peripheral smear - Anisopoikilocytosis with hypochromia with microcytes, macrocytes and pencil cells. 

CLINICAL IMAGES

PROVISIONAL DIAGNOSIS 

Pancytopenia 2°to vitamin B12 deficiency.

TREATMENT

INJ. VITCOFOL 1000mcg/IM/OD × 7 days

INJ. OPTINEURON 1AMP in 100ml

TAB. PANTOP 40mg/PO/OD