Medicine case

Hello all , I’m an intern and here is a case history of  one of our patients who got admitted .

This is to complete my log book as a part of my internship duty. 

Edit:I was not there in the op so i collected the hirtory part from my co- intern and i had to type the discharge letter so i added extra points about the examination and investigations part . So we both helped each other. 

11/04/2020

A 47 year old female presented to OPD with complaints of 

Difficulty in breathing since 10 days not aggravated or relieved with positional or diurnal variation 

palpitations since 10 days  which were short lasting

Bilateral pitting type of edema of lower extremities  since 10 days 

No h/o pain or warmth at the local sites of edema , no color change

No h/o facial puffiness or abdominal distention.

Bp :   130/90 mmhg

Pulse: 88 bpm

Temp: afebrile

She is a known hypertensive pt since 20 years .she is on medication tab . Telmisartan 20mg daily

H/o filariasis in rt lower limb since 15 years and is using medication DEC 100 mg for 2 weeks in a year.

  ON EXAMINATION 

 Pt was c/c 

Temperature:96.5 F

Bp:130/90mm Hg

Pulse:84 bpm

Spo2: 99%

CVS: S1 S2 heard

RESPIRATORY SYSTEM: normal vesicular breath sounds

P/A: shape of the abdomen: obese

        No free fluid ,scars ,sinuses

        Hernial orifices normal

         No tenderness 

          Liver is palpable 2-3 cms

         Spleen is palpable- 4 cms

          Bowel sounds present

 CNS: HMF intact

           Speech normalk

           Sensory system normal 

            Motor system normal


INVESTIGATIONS

 Hemogram:    On presentation she had hb-4.5 gm/dl .After 1 st blood transfusion          On12/05/20 hb:6.2 gm/dl

                    Total count:14,200 cells/cumm

                     Pcv:18.3 vol

                      Rbc:1.96 millions/cumm

                       Platelet: 1.01 lakhs/cumm

After 2 ndblood tranfusion

    On 15/05/20 hb: 9gm/dl

                      Pcv:28.6 vol%

                       Mchc:31.3%

                       Rdw-cv 19.5% 

Serum iron- 40ug/dl

Serum ferritin- 109ng/ml

 Rft: urea- 10mg/dl

        Sodium-139mEq/l

         Potassium-4.1mEq/l

         Chloride-104mEq/l

Lft:Total bilirubin-1.28mg/dl

       Direct bilirubin-0.52mg/dl

        SGOT-24IU/L

         SGPT-12IU/L

         Alkaline phosphate- 118IU/L

         Total proteins - 5.7gm/dl

          Albumin-3.7gm/dl

 Smear:

RBC:hypochromic with anisopoikilocytosis comprising 

normocytes ,macrocytes ,tear drop cells,Schistocytes

,polychromasia and nucleated rbcs 2-3 / 100 wbc 

WBC: normal count with hypersegmented neutrophils and mild shift to left

Platelets: adequate

No parasites

Impression: normocytic hypochromic anemia with 

hypersegmented neutrophils

             -? Megaloblastic anemia

              -? Hemolytic anemia

Osmotic fragility-lysis starts at 0.45%

                              Completes at 0.33%

Stool culture: no pus cells,no rbcs, no parasitic forms of ova / cyst seen

Stool for occult blood: positive

USG abdomen-splenomegaly

                          Fibroid uterus 

                          Right hydrosalpinx

2d echo: mild dilated R.A/ R.V 

PROCEDURE LEARNT: BONE MARROW ASPIRATION ( site- sternum) done on 13/05/20

First consent was taken from the patient. Then the patient was given a test dose of xylocaine. After half and hour at the level of 2 nd intercoastal space 10ml xylocaine was 

given then marrow was aspirated .

  Report: reactive marrow with erythroid 

   




DIAGNOSIS: 

      ?megaloblastic anemia

       ?hemolytic anemia

TREATMENT GIVEN:

Planned for 2 prbc blood transfusion

Inj. Vitcofol 2cc/im/od (D 3/5)

T.livogen  150mg/po/od for 1 month

T.MVT/po/od

Inj methylcobalamine  1 amp/im/od 500 mcg for 5 days (D1/5)

  

ADVICE AT DISCHARGE:

Inj. Hydroxocobalamin 1000 mcg for 3 days. Followed with weekly once for 1 month. Later on monthly once for 2 months

T. MVT po od for 1 week

          

TOPIC LEARNT TODAY:SUBARACHNOID HEMORRHAGE

etiology:

Rupture of aneursyms( most common)

Trauma

Av malformations

Vasculitis

Intracranial arterial dissections

Amyloid angiopathy

 Bleeding diathesis

Drug use( cocaine and amphetamines)

   

Clinical features: 

Sudden severe headche (thunderclap headache) described as the “worst headache of my life”

Headache associated with loss of consciousness , seizure, nausea and vomiting

Investigations :

1)Plain ct head: clot demonstrated within 24 hours of the bleed

2)Lumber puncture: elevated opening pressure and a uniformly blood stained CSF . Xanthrochromia represents hb degradation products suggestive of SAH

3)Angiogram: nature and location of lesion

4)CT or angiography

Treatment:

 1 )admit in icu

2)bed rest ,stool softeners,adequate analgesia

3)DVT prophylaxis

4)discontinue all anticoagulants and antiplatelet agents

5)reduction of intracranial pressure- head end elevation, mannitol,loop diuretics, use of iv steroids(dexamethasone)

6)reduction of bp- labetalol infusion

7)prevetion of vasospasm- nimodipine 

8)seizure prophylaxis

9)treatment of aneurysm and av malformations: placement of a clip across the neck of aneurysm or endovascular techniques with coil placement

Complications

 1)rebleeding

2)vasospasm

3)hydrocephalus