Case history 03

Case history GM 03

 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 patient's clinical problems with collective current best evidence based inputs

DATE OF ADMISSION:  04- September-2021

A 70 year old patient, farmer by occupation came to OPD with chief complaints of

Shortness of breath since 20 days

Leg pain on walking since 20 days

Fever and weakness since 3 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 20 days back. Then he developed shortness of breath which on walking for short distance ( grade 3) since 20days. Patient complaints of left leg pain on walking since 20days. There is pedal edema of left leg and foot which is pitting type 8 days back.          

There is history of trauma to left leg 3months back.

There is history of high grade, intermittent fever for which the patient was admitted to local hospital for treatment 3months back. The fever subsided on medication. 

Patient suffers from severe weakness and tiredness and unable to walk from 3days.

There is no history of cough, vomitings and diarrhea.

There is no loss of appetite and weight.

There is no history of body pains.


PAST HISTORY: 

There is history of blood transfusion(4 units) 10days back .  After transfusion, patient  complaints of red colour urine and fever for 2 days.

There is no history DM, hypertension, asthma and epilepsy.

PERSONAL HISTORY:

Patient is married with 2 children.

Appetite: Normal

Diet : mixed ( non vegetarian)

Sleep: adequate

Bowel habits: regular

Micturition: normal

Patient used to consume alcohol occasionally.

FAMILY HISTORY: 

There is no history of similar complaints in the family. There is no history of cancer and sudden deaths in the family.

DRUG ALLERGY:

patient is not allergic to any known drug.

GENERAL EXAMINATION:

Patient is coherent , cooperative and coherent and well oriented to time, place and person.

Patient is moderatly built and nourished.

Pallor is seen. There is no clubbing.

No cyanosis, icterus and lymphadenopathy.





VITALS:

Temp :Afebrile
PR : 90bpm
RR :17cpm
BP :110/70mmHg
SpO2: 98% in room air
GRBS :159mg/dl
 

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Inspection: 

Chest wall is bilaterally symmetrical

No Precordial bulge

No visible pulsations, engorged veins,scars, sinuses

Palpation:

JVP - normal

Apex beat : felt in the left 5th intercostal space

In midclavicular line 

Ausculation:

S1 ,S2 Heard


RESPIRATORY SYSTEM

Bilateral airway +

Position of trachea- central

Normal vesicular breath sounds - heard

No added sounds


PER ABDOMEN

Abdomen is soft and non tender 

Bowel sounds heard

No palpable mass or free fluid 

CENTRAL NERVOUS SYSTEM

Patient is conscious 

Reflexes are normal 

Speech is normal

PROVISIONAL DIAGNOSIS

Pancytopenia under evaluation

INVESTIGATIONS

      HAEMOGRAM:























 
TREATMENT : 
DAY 1
S 
Patient has reduced weakness
O
Pallor +
Clubbing -
PR -  87 bpm
BP - 110/70mmhg
Afebrile 
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vit B12 defeciency
P
1. Inj METHYLCOBALAMINE 1000mg IV OD
2. Inj IRON SUCROSE 1 amp in 100ml NS IV
3. Vitals monitoring

Day 2
S
Patient has reduced weakness
O
Pallor +
Clubbing -
PR -  87 bpm
BP - 110/70mmhg
Afebrile 
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vit B12 defeciency
P
1. Inj METHYLCOBALAMINE 1000mg IV OD
2. Inj IRON SUCROSE 1 amp in 100ml NS IV
3. Vitals monitoring

Day 3
S
Patient has reduced weakness
O
Pallor +
Clubbing -
PR -  87 bpm
BP - 110/70mmhg
Afebrile 
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vit B12 defeciency
P
1. Inj METHYLCOBALAMINE 1000mg IV OD
2. Inj IRON SUCROSE 1 amp in 100ml NS IV
3. Vitals monitoring

Day 4
Patient taken to Gen surgery opd for PR examination and to evaluate the presence of any hemorrhoids. No abnormality detected.
Also taken for gastroenterology referral to rule out any gi bleeding. Endoscopy was not performed in view of low platelet count. Bone marrow biopsy was adviced.
S
Patient has reduced weakness
O
Pallor +
Clubbing -
PR -  87 bpm
BP - 110/70mmhg
Afebrile 
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vit B12 defeciency
P
1. Inj METHYLCOBALAMINE 1000mg IV 0D
2. Inj IRON SUCROSE 1 amp in 100ml NS IV
3. Vitals monitoring

Day 5
S
Patient has reduced weakness
O
Pallor +
Clubbing -
PR -  87 bpm
BP - 110/70mmhg
Afebrile 
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vit B12 defeciency
P
1. Inj METHYLCOBALAMINE 1000mg IV 0D
2. Vitals monitoring
Day 6
S
Patient has reduced weakness
O
Pallor +
Clubbing -
PR -  87 bpm
BP - 110/70mmhg
Afebrile 
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vit B12 defeciency
P.
1. Inj METHYLCOBALAMINE 1000mg IV 0D
2. Vitals monitoring

Day 7
S
Patient has reduced weakness
O
Pallor +
Clubbing -
PR -  78 bpm
BP - 110/80mmhg
Afebrile 
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vit B12 defeciency
P
1. Inj METHYLCOBALAMINE 1000mg IV 0D
2. Vitals monitoring

Day 8
S
Patient c/o 2 fever spikes(101F)
O
Pallor +
Clubbing -
PR -  78 bpm
BP - 100/70mmhg
Afebrile 
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vit B12 defeciency
P
1. Inj CEFTRIOXONE 1gm iv/bd
2. Tab VIT B12 po/od

Day 8
S
Fever spike in the morning
Not able to walk due to shivering in the legs during the fever spike
O
Pallor +
Clubbing -
PR -  66 bpm
BP - 100/60mmhg
Afebrile 
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vitt B12 defeciency
P
1. Inj CEFTRIOXONE 1gm iv/bd
2. Tab VIT B12 po/od

Day 9
S
Fever spike in the morning
Not able to walk due to shivering in the legs during the fever spike
O
Pallor +
Clubbing -
PR -  87 bpm
BP - 110/70mmhg
Afebrile 
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vitt B12 defeciency
P
1. Inj CEFTRIOXONE 1gm iv/bd
2. Tab VIT B12 po/od

Day 10
S
C/o fever spike in the morning
Not able to walk due to shivering in legs1
O
Pallor +
Clubbing -
PR -  85 bpm
BP - 100/60mmhg
Temp - 101.8 F
Spo2 - at 99% on RA
RR - 14 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
CUE
Color pale yellow
Appearance clear
Alb nil
Sugar nil
Bile salts and pigments nil
Pus cells 2-3
Epith cells 2-3
A
Pancytopenia under evaluation
?Vit B12 defeciency ?MDS
P
1. Inj CEFTRIAXONE 1gm iv/bd
2. Tab VIT B12 po/od
3. Monitor vitals 4 th hrly


    Day 11
S
C/o 2 fever spikes
Generalised weakness
O
Pallor +
Clubbing -
PR -  82 bpm
BP - 100/60mmhg
Temp - 101.8 F
Spo2 - at 99% on RA
RR - 16 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
P
1 unit SDP transfusion done yesterday. Serology for HIV, HbsAg and HCV all negative. Planned for bone marrow biopsy today.
1. Tab VIT B12 po/od
2. Tab PCM 650mg po/sos
3. Tepid sponging
4. Monitor vitals 4th hrly


Bone marrow aspiration and biopsy was done in the afternoon .

Patient had 2 episodes of vomiting ,and suddenly became breathless ,with profuse sweating ,cold peripheries ,feeble pulse ,BP -80/60 mmHg 
Spo2 on room air -52 % 
RR-38/ min 
HR-110/ min 

RS- Bae+ , clear 
CVs -s1,S2 heard no murmurs .

ABG - severe metabolic acidosis - 
PH-7.2 
Hco3-5
Paco2- 9.2

Assessment- septic shock ? / Cardiogenic shock ? 
Heart failure 
Severe anemia 

Plan - O2 inhalation 
Ionotropic support- on noradrenaline .
Started on Piptaz 
PRBC transfusion 



 On 16th of september, patient was declared dead.

Questions:
1. Patients complaints of red color urine after transfusion of blood. What is the cause of it?
2. As severe anemia cause heart failure. How anemia can cause septic shock?




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