General medicine case 4


 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

A 70 yr old male patient presented to opd with chief complaints of shortness of breath since 20 days , leg pain on walking since 20 days , pedal edema since morning on 4th September
 
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 45 days back. Then the patient developed shortness of breath which is grade 3 since 20 days and leg pain since 20 days there is history of trauma of his left leg 3 months back.complaints of pitting type of edema involving left leg.

Patient had fever 2 months back which subsided on medication 

Patient complaints of fever which is intermittent and cough since 3 to 4 days . patient also complaints of tiredness and weakness. Patient is unable to walk . There is no history of body pains on 13th September 2021
 
HISTORY OF PAST ILLNESS
There is no history of hypertension, diabetes mellitus , tuberculosis, asthma, and epilepsy

There is history of blood transfusion (4 units ) Suryapet 10 days back

PERSONAL HISTORY
Diet is mixed , vegetarian
Sleep is adequate
Bowel and bladder movements are regular 
Appetite is normal
There is no history of allergies to known drugs
Patient was drinking alcohol occasionally 4 yrs back then stopped drinking
He is married and has 2 children

FAMILY HISTORY
There is no history of similar complaints in the family members

GENERAL EXAMINATION
The patient is conscious, coherant and cooperative. He is well oriented to time , place and person . Moderately built and nourished
Anemia present
Pallor present
No icterus
No cyanosis
No clubbing
No generalized lymphadenopathy
















































VI
Vitals 
PR 90bpm
RR 17cpm
BP 110/70mmHg
SpO2 98% in room air
GRBS 159mg/dl
Temperature febrile

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





















TREATMENT
1. Inj METHYLCOBALAMINE 1000mg IV OD
2. Inj IRON SUCROSE 1 amp in 100ml NS IV
3. Vitals monitoring

Bone marrow aspiration and biopsy was done in the afternoon .
On 16th September

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 
( Informed to first on call sir on duty ) .

On 16th September Patient was declared as death 

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