General medicine case 4
The patient history was taken from psychiatry notes written by Dr.Sravanthi mam.
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20 September 2021
30 yr Male came to casuality with chief compaint of pedal edema and shortness of breath since one month .
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 month back ,and then he developed pedal edema(pitting type)and sob(grade2)
He has fever since 3days associated with chills.
He has cough from 20days.
PAST HISTORY:
He had similar complaints 5 yrs back and workup for anaemia.
No history of hypertension, diabetes,asthma and epilepsy.
PERSONAL HISTORY:
Decreased appetite
Diet - Non vegetarian
Sleep is adequate
Bowel and bladder - Normal
Micturition - normal
No addictions
FAMILY HISTORY:
No similar complaints in the family.
GENERAL PHYSICAL EXAMINATION:
Patient is conscious, coherent and co-operative.
Pallor -Severe
Mild icterus
Mild cyanosis ,clubbing is present
edema of feet - pitting type
Abdominal distension is present
VITALS
Temp -afebrile
bp - 110/50 mmHg
PR - 110 bpm
RR - 20
Spo2 - 98%
SYSTEMIC EXAMINATION:
CVS :
No thrills
S1, S2 heard
S3 gallop heard
No cardiac murmurs
RESPIRATORY SYSTEM:
Dsypnoea - present
No wheezing
Position of trachea - central
Breath sounds - vesicular
ABDOMEN:
Shape of abdomen:distended
No tenderness
Mild hepatomegaly
No bruits
Liver - not palpable
Spleen - not palpable
Bowel sounds are present
CNS:
No abnormality detected.
INVESTIGATIONS:
HEMOGRAM:
Total Leucocyte Count:9850cells/cu mm
RBC:0.58 mill/cu mm
Hemoglobin:3.1gm/dl
Platelet Count:61000 lakhs/cu mm
Anti HCV antibodies - non reactive
HBsAg - negative
HIV - negative
LFT:
Total Bilurubin:4.94mg/dl
Direct Bilurubin:0.65mg/dl
AST:60IU/L
ALT:15IU/L
ALP:103IU/L
Albumin:2.9gm/dl
RFT:
Serology - negative
Urea - 22mg/dl
Creatinine - 0.7mg/dl
LDH - 2426
Sodium - 136mEq/L
Potassium - 3.8mEq/L
Chlorine - 102mEq/L
CUE:
Albumin:nil
Sugar:nil
Pus cells:3-4
Epithelial cells:2-3
ULTRASOUND REPORT:
ECG:
2D ECHO:
CHEST X-RAY:
FEVER CHART:
PROVISIONAL DIAGNOSIS:
Anaemia secondary to vit B12 deficiency with thrombocytopenia.
Right heart failure.
TREATMENT:
1)Bp/PR/Temp 4th hr
2)Inj.Optineuron 1amp in 100ml
3)Tab.MVT PO/OD
4)Inj.Lasix 40mg iv/BD
5)Tab.PCM 500mg /sos
6)Inj.Ceftriaxone 1gm Iv/BD
7)Fluid restriction <1.5 L/day
8)i/o charting.
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