This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability.
Mentioned here are my learning points, both theoretical and practical surrounding this patient:
-This patient's history was the first history I took during my Medicine postings in internship. My PG taught me how to take an extensive psychosocial history, and how to take nutritional history- which is relevant to this patient with anemia. Taking a proper psychosocial history allowed me to develop a better understanding of what the patient's knowledge on the topic was, and what exactly were the issues around her disease that burdened her.
-I learnt the basics of 2D ECHO, how to identify the chambers of the heart and how to approximate ejection fraction. I've attached the 2D ECHO video at the end of the blog.
-In this patient, as heart failure was being suspected due to mild raised JVP, an interesting discussion ensued, of whether or not to start a blood transfusion- since she had symptoms of heart failure and a transfusion would further exacerbate it by increasing preload. I learnt how to navigate such dilemmas to optimize patient care.
A 43 year old female, who is a resident of Narketpally came to the OPD with chief complaints of :
-Swelling in bilateral lower limbs upto ankle since 15 days
-Generalised weakness since 1 week
HISTORY OF PRESENTING ILLNESS:
The patient was apparently asymptomatic 4 years ago, when she has symptoms of generalised weakness. Hence, she visited her local doctor. Blood investigations were sent at the time, and a hemoglobin of 6gm/dl was noted. She could not recollect the other investigations sent, and did not have the reports with her. For her low hemoglobin levels, she was advised iron and folic acid supplements, which she took for a month and stopped.
15 days ago, she noticed swelling in both her lower limbs until her ankle, which was insidious in onset , gradually progressive in nature, pitting type. The swelling was not associated with any aggravating and relieving factors.
She had a history of shortness of breath since 1 week, which was intermittent and non progressive. She had difficulty breathing while walking u the stairs, or while brisk walking- grade II NYHA classification
These symptoms were not associated with any facial puffiness, orthopnea, paroxysmal nocturnal dyspnoea
She also noted generalised weakness since 1 week
She noted no history of decreased urine output, burning micturition
She had no history of abdominal distension, abdominal pain, itching, erythma
She had no history of vomiting, loose stools or constipation, fever
PAST HISTORY:
In 2004, she started having back pain and itching in her vaginal area, for which she consulted a gynaecologist. She was diagnosed with a growth (?polyp) in her uterus and was given medication for it, which she used for two months. The patient could not recall the medication that she used.
She had no other symptoms till 2019, which was when she first noticed intermenstrual bleeding, which occurred for 2 months. Again she visited the gynaecologist and was given medication for it, after which it decreased.
MENSTRUAL HISTORY:
Menarche attained at 13 years
28/5 - regular
Increased menstrual bleeding on 1st 2-3 days since 3 months
Uses 5 pads per day
Not associated with pain, clots.
PERSONAL HISTORY:
Diet - mixed
Breakfast - Idly /dosa with chutney /chapathi with curry
Lunch - 1 cup rice with vegetable curry
Dinner - 1 cup rice with vegetable curry
Consumes meat twice or thrice a month .
Sleep - Adequate
Appetite - normal
Bowel and bladder - regular
No addictions
No allergies
MARITAL, OBSTETRIC HISTORY
She studied till the 10th grade, after which she was married off at the age of 15 years. She has two younger brothers.
In 1995, she gave birth to her 1st child who died after 3 days.
In 1997, she gave birth to a girl who died at the age of 6.
Later with spacing of 3 years she gave birth to her 3rd child, who is in college.
In 2002 , she gave birth to her 4th child
In 2004, she gave birth to her 5th child
DAILY ROUTINE :
Earlier, she used to wake up by 6 am ,do her household work, eat breakfast by 9 am and go to work at her general store. At around 2 pm, she would have lunch and then get back to work. She would leave work at 9, make dinner and eat at around 10pm, and sleep by midnight.
After she noticed pedal edema , she stopped sitting for long periods of time as she thought that was the cause. Because of her weakness, she stopped going to her general store and instead rested at home.
Since a few months, the patient mentioned that she had not been eating properly. She barely ate two meals a day, and when she did she ate very little. There were days when she ate nothing at all, for 2-3 days at a time. She stated that the main reason for this was that she was facing psychological distress from family problems, and was worried about making ends meet. Currently, the family's main source of income was the general store, which she was taking care of alone. Additionally, doing the household work as well as caring for the children was taking a toll on her. She sadly noted that even admission in the hospital meant more worry for the family.
FAMILY HISTORY:
No significant history
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative.
She is moderately built and moderately nourished.
Pallor - Present
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
No lymphadenopathy
On examination, pedal edema is present below knee level
Vitals :
Temperature - 96.8 ° F
Blood Pressure -110/70 mmHg
Pulse Rate -100 bpm
Respiratory Rate - 16 cpm
RBS - 158 gm/dl
SYSTEMIC EXAMINATION:
PER ABDOMINAL EXAMINATION:
INSPECTION-
Shape of abdomen : flat
Umbilicus : inverted
All quadrants of abdomen move with respiration
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites
PALPATION-
Abdomen soft
No local rise of temperature
No tenderness
Inspectors findings are confirmed
No palpable masses
Liver is not palpable
Spleen is not palpable
PERCUSSION:
Resonance note heard over all quadrants
AUSCULTATION:
Bowel sounds heard
CVS EXAMINATION:
INSPECTION
The chest wall is bilaterally symmetrical
JVP mildly raised
No dilated veins, scars or sinuses are seen
Apical impulse not visible
PALPATION:
Apex beat is felt in the fifth intercostal space, 1 cm medial to the midclavicular line
No precordial bulge noted
No parasternal heave noted
AUSCULTATION:
S1 and S2 heard, no murmurs heard
RS EXAMINATION:
INSPECTION:
Shape of chest: bilaterally symmetrical
Expansion of chest: Equal on both sides
Position of trachea: Central
Supraclavicular and infraclavicular areas normal
Spinoscapular distance normal
No crowding of ribs
No kyphoscoliosis
No visible scars, sinuses, pulsations
PALPATION:
Inspectory findings confirmed
No tenderness, local rise of temperature
Normal expansion of chest on both sides in all areas
Position of trachea: Central
Vocal fremitus: resonant note felt
PERCUSSION:
Resonant note heard over all areas
AUSCULTATION:
BAE positive
Vocal resonance: resonant in all areas
CNS EXAMINATION:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
CRANIAL NERVES-
Normal
SENSORY EXAMINATION
Normal sensations felt in all dermatomes
MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
PROVISIONAL DIAGNOSIS:
Anemia under evaluation
Etiology: Nutritional? Menstrual blood loss?
EVALUATION:
On 7 June 2023:
Complete Blood picture:-
Serum electrolytes
ECG
Heart rate -100 bpm ( tachycardia)
Normal sinus rhythm
Non specific ST segment changes
Low voltage QRS in lead aVF
Normal axis
On 13 June 2023
Hb- 5gm/dl
TLC - 5800
MCV - 61.7
MCHC - 23.1
MCH - 14.3
Platelet - 3.0
Serum iron - 31 micro gram / dl
Blood urea - 22 mg/dl
Serum creatinine - 0.6 mg/ dl
Blood grouping - B +ve
Serum ferritin - 2.2
FBS: 285mg/dl
PLBS:
Chest x-ray
USG:
Positive findings - borderline splenomegaly
Right renal calculi
2DECHO:
DIAGNOSIS:
Severe anemia secondary to ?Nutritional cause
Denovo Diabetes Mellitus
TREATMENT PLAN:
IRON SUCROSE 200MG IN 100ML NS IV WAS GIVEN TWICE
INJ OPTINEURON 1 AMPOULE IN 100ML NS
TAB GLIMIPERIDE 1MG PO OD
TAB METFORMIN 500MG PO OD
ADVICE AT DISCHARGE:
TAB GLIMIPERIDE 1MG PO OD BEFPRE FOOD AT 8AM TO CONTINUE
TAB METFORMIN 500MG PO BD AFTER FOOD AT 8AM AND 8PM TO CONTINUE
TAB OROFER XT PO OD AT 2PM FOR 1 MONTH
TAB BEPLEX FORTE AT 2PM FOR 15 DAYS
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