20 YEAR OLD FEMALE WITH MEGALOBLASTIC ANEMIA

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I have been given this case to solve in an attempt to understand the topic of  " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 20 year old female patient , who is a student, presented to the opd with chief complaints of 

1) Yellowish discoloration of sclera since 6 months ,

2) Burning sensation in B/L lower limbs since  6 months. 

3) Weakness since 6 months ,

4) Loss of appetite since 6 months,

5) Weight loss over last 6 months. 

HOPI :-

The patient was apparently asymptomatic 6 months ago, when she developed yellowish discoloration of sclera for which she took some herbal medicine for 2 days and stopped. 

Over a period of time, she develeoped burning sensation in B/L lower limbs along with weakness. Patient also gives history of weight loss around 10 to 12 kgs of weight .

Patient gives history of passing dark coloured stools sometimes.

No h/o fever,  drug intake.

No h/o hematuria and rashes. 

She gives h/o visiting local hospital 2 days back where they performed tests which are as follows-

1)Total bilirubin- 7g/dl

2) Direct bilirubin- 3g/dl

3)Hemoglobin- 4g/dl

4) TLC- 3300

5) Platelets - 1.3 L / cumm

 PERSONAL HISTORY- 

 No history of fever or other related infections . 

 Loss of appetite.

 Bowels regular - No complaints of dark coloured stools.

 No hematuria . 

Born out of first degree consanguineous marriage . 

DIETARY HISTORY-

For the past 6 months -

Vegan and restricted diet.

Before the 6 months prior to admission in the OPD - 

Non - vegetarian diet

 FAMILY HISTORY -

Multiple members of the family suffer from hypertension. 

 

ON EXAMINATION:- 

Patient is conscious,  coherent and cooperative. 

Pallor and Icterus are present. 

Vitals- PR =88bpm

            BP= 105/60 mmhg

            RR= 14cpm

            TEMP= afebrile 

            SPO2= 100% at room air.

CVS:-

S1, S2 heard 

Palpable P2

Parasternal heave is present. 

RESPIRATORY SYSTEM :-

BAE+

NVBS heard

PER ABDOMEN :-

Shape of the abdomen is scaphoid. 

Tenderness is present in Right hypochondrium. 

Liver and spleen are not palpable. 

Bowel sounds are heard.

CNS :-

Patient is conscious. 

Speech is normal.

No signs of meningeal irritation. 

Reflexes are normal.

PSYCHIATRY REFERRAL:-

Patient was sent for psychiatry referral in the view of  to rule out

Anorexia nervosa, Bullemia nervosa, Anxiety disorder. 

IMPRESSION GIVEN BY DEPT OF PSYCHIATRY:- Adjustment disorder  ( depression and anxiety secondary to general medical illness and its treatment).

Plan:- patient and mother are psychoeducated.

Individual psychotherapy session done.

Tab. Mirtaz 7.5 mg po/od.

Tab. Lomazep md 0.25 mg/po/sos ( if amxious or restless or disturbed sleep).

PROVISIONAL DIAGNOSIS  :-

MEGALOBLASTIC ANEMIA WITH ADJUSTMENT DISORDER  ( DEPRESSION AND ANXIETY).

INVESTIGATIONS:-

HEMOGRAM 

CUE

PERIPHERAL SMEAR

MALARIA PARASITE

ESR

RETICULOCYTE COUNT

USG ABDOMEN 

CXR

ECG

TREATMENT :-

1)Date- 30.6.2021

• Inj. Pantop 40mg IV/OD.

• Monitor vitals

• Strict I/O charting.

2) Date - 1.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/OD.

3) Date - 2.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/OD.

4)4)

Date - 3.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/BD.

5)Date - 4.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/BD.

6) Date - 5.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/BD.

7) Date - 6.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/BD.

8) Date - 7.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/BD.

9) Date - 8.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/BD.

10) Date- 9.7.2021

Advice at discharge:

1) Inj Vitcofol 1amp IM every week for 4 weeks.

2) Tab.Riboflavin 10mg PO/BD for 1 month 

3) Tab Zincovit PO/OD for 1 month.

4) Tab.Orofer XT PO/BD for 1 month (before food)

5) Tab Limcee PO/OD for 1 month (before food)

6) Daily 1egg/day.

7) Tab. Pregabalin 75mg SOS

COURSE IN THE HOSPITAL:-

This is a case of 20yr old female with anaemia secondary to deficiency of Vitamin B12 and Folic acid.( Megaloblastic.A).The patient was admitted one week back and was treated with Inj Vitcofol For B12 and Folic acid supplementation and Tab Riboflavin 10mg BD and Tab Zincovit  for multivitamin supplementation every day and was advised discharge and review to the OPD after 15 days.

DISCHARGE TEMPLATE:- 

1)Date- 30.6.2021

• Inj. Pantop 40mg IV/OD.

• Monitor vitals

• Strict I/O charting.

2) Date - 1.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/OD.

3) Date - 2.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/BD.

4)

Date - 3.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/BD.

5)Date - 4.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/BD.

6) Date - 5.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/BD.

7) Date - 6.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/BD.

8) Date - 7.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/BD.

9) Date - 8.7.2021

•Inj. Pan 40mg IV/OD

• Tab. Folic acid 5mg PO/OD.

• Tab. Zincovit PO/OD.

• Inj. Vitcofol 1amp IM/BD.

10) Date- 9.7.2021

Advice at discharge:

1) Inj Vitcofol 1amp IM every week for 4 weeks.

2) Tab.Riboflavin 10mg PO/BD for 1 month 

3) Tab Zincovit PO/OD for 1 month.

4) Tab.Orofer XT PO/BD for 1 month (before food)

5) Tab Limcee PO/OD for 1 month (before food)

6) Daily 1egg/day.

7) Tab. Pregabalin 75mg SOS