A CASE OF A 61 YEAR OLD MAN WITH BICYTOPENIA UNDER EVALUATION






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. This e-log book reflects my patient centered online portfolio and your valuable inputs on the comments is welcome.”

A 61 year old male resident of Ramulapeta,yadadri dist who is a daily wage labourer in construction work came to the hospital with complaint of

CHIEF COMPLAINTS
Dry cough since 10 days
 Dragging pain towards the finger tips since 10 days
Lower back pain since 10 days
Shortness of breath Grade 2 -grade 3
Chest pain near heart since 10 days



 HISTORY OF PRESENTING ILLNESS
PATIENT WAS APPARENTLY ASYMPTOMATIC 3 YEAR AGO WHEN 
He noticed involuntary movements of upper right limb at rest and decreased on movement
2 years ago his wife passed away  because of which he became reclusive and increased intake of alcohol 
1 year back he noticed showing of moments and decrease in his pitch of voice
He has used medication but stopped using after 5 months due to lack of improvement of symptoms
Since 20 days back he has trouble recollecting and takes at least 30-40 minutes if he wants to do something
Like bringing a article from home

Then 10 days back he experienced dry cough 

Lower back pain on both sides draging type radiating towards the coccyx 
Parn in upper right arm radiating towards the finger tips dragging in nature 
Both of which were relieved on medication and rest

Chest pain more of a burning sensation since 10 days 

Shortness of breath Grade 2 -3
Not relieved on rest 
No association with  vomiting or headaches



PAST HISTORY

10 days back had a episode of fever which subsided on medication
Not a known case of
Diabetes 
Hypertension
Tb 
Asthama
Epilepsy
Cvd
Chemotherapy

FAMILY HISTORY
Not significant

PERSONAL HISTORY
Diet - mixed
Appetite - Decreased 
Bowel and bladder - adequate
Allergies -no
Addiction - after demise of wife he sought these
18 ciggarette per day and alcohol

Daily routine before 10 days
5:00 woke up
6-7:00 had breakfast
9:30 went to work
1:00 lunch
6:30_7:00 comes back and watches tv
8-9:00 dinner
9:30 sleep

Daily routine after pain
Stopped going to work
Still wakes up at 5  but then 
Eats and sleeps 
Sometimes watches tv


GENERAL EXAMINATION
Thin built and malnourished 

Vitals
Temperature : Afebrile 
Pulse: 81
BP:110/80 mm/ hg
RR :18 
SPO2 : 97%


Pallor : present 


Icterus present
Clubbing absent
Cyanosis absent
Lymphadenopathy absent
Pedal edema absent
JVP RAISED 





SYSTEMIC EXAMINATION
CVS
Apex beat 6 th intercoastal space
No thrills
S1 S2 heard
No murmurs

RESPIRATORY SYSTEM


No dyspnoea wheeze
Central trachea 
Bilateral air entry +
Bilateral basal crepts +


ABDOMEN
Soft

Non tender



CNS
Higher functions
Patient is conscious, coherent,and co operative
Patient is oriented to place not to time and person
Delay in response but able to recall

Crainal nerve intact



Examination of motor system 
Tone increased on right upper limb
Not able to approximate both upper limbs
Power of muscle normal

Coordination of movement 

Tremors : resting
                 pill rolling movement
Reflex

Sensory system
Normal

INVESTIGATION


Day 1 
Day 3

Day 4

Day 5





Day 6


Day 7



Day 8


Day 9













Peripheral blood smear on 8th


Peripheral blood smear on 10th

Peripheral blood smear On 11th



PROVISIONAL DIAGNOSIS
BICYTOPENIA  SECONDARY TO PLASMA CELL DYSCRACIA
WITH
COMMUNITY ACQUIRED PNEUMONIA WITH (BILATERAL LOWER LOBE CONSOLIDATION)
WITH 
MODERATE HEPATOSPLEENOMEGALY
WITH
HYPONATREMIA (RECOVERED )2 TO SIADH? 
ALTERED MENTATION




Day 1

S :- 
Patient is having resting tremors
Delayed speech
Altered sensorium

O:-
Pt is conscious, coherent cooperative

Bp:-140/70
Pr:-92 bpm
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender spleenomegaly
CNS:- NAD

A:-
BICYTOPENIA UNDER EVALUATION
WITH
 COMMUNITY ACQUIRED PNEUMONIA WITH PARKINSON'S(?)WITH 
MODERATE SPLEENOMEGALY

P:-
Inj AUGMENTIN 1.2g/IV/BD
TAB AZITHROMICIN 500 mg/PO/OD
INJ OPTINEURON 1 amp 100 ml /NS
Vital monitoring
Temperature monitoring


Day 2

S :- 
Patient is having resting tremors
Delayed speech

O:-
Pt is conscious, coherent cooperative

Bp:-120/70
Pr:-93 bpm
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender spleenomegaly
CNS:- NAD

A
BICYTOPENIA UNDER EVALUATION
WITH
 COMMUNITY ACQUIRED PNEUMONIA WITH PARKINSON'S(?)WITH 
MODERATE SPLEENOMEGALY

P:-
Inj AUGMENTIN 1.2g/IV/BD
TAB AZITHROMICIN 500 mg/PO/OD
INJ M6RVIG6M1000 micrograms//IV/OD IN 50 ML NS
INJ OPTINEURON 1 amp 200 ml /NS
Vital monitoring
Temperature monitoring

Day 3

S :- 
Patient is having resting tremors
Delayed speech
O:-
Pt is conscious, coherent cooperative

Bp:-110/80
Pr:-86 bpm
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender spleenomegaly
CNS:- NAD

A:-BICYTOPENIA UNDER EVALUATION
WITH
 COMMUNITY ACQUIRED PNEUMONIA WITH PARKINSON'S(?)WITH 
MODERATE SPLEENOMEGALY

P:-
Inj AUGMENTIN 1.2g/IV/BD
TAB AZITHROMICIN 500 mg/PO/OD
INJ M6RVIG6M1000 micrograms//IV/OD IN 50 ML NS
TAB PANTOPRAZOLE 40 MG/PO/OD
Vital monitoring
Temperature monitoring

Day 4

S :- 
Patient is having resting tremors
Delayed speech
O:-
Pt is conscious, coherent cooperative

Bp:-110/80
Pr:-86 bpm
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender spleenomegaly
CNS:- NAD

A:-BICYTOPENIA UNDER EVALUATION
WITH
 COMMUNITY ACQUIRED PNEUMONIA WITH PARKINSON'S(?)WITH 
MODERATE SPLEENOMEGALY

P:-
Inj AUGMENTIN 1.2g/IV/BD
TAB AZITHROMICIN 500 mg/PO/OD
INJ M6RVIG6M1000 micrograms//IV/OD IN 50 ML NS
TAB PANTOPRAZOLE 40 MG/PO/OD
Vital monitoring
Temperature monitoring





Day 5
S :- 
Patient is having resting tremors
Fever spikes
Shortness of breath
Pain at bone marrow biopsy site
Delayed speech
O:-
Pt is conscious, coherent cooperative

Bp:-110/70
Pr:-92 bpm
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender spleenomegaly
CNS:- NAD

A:-BICYTOPENIA UNDER EVALUATION(2 to malignancy infection) 
WITH
 COMMUNITY ACQUIRED PNEUMONIA WITH ESSENTIAL TREMORS WITH 
MODERATE SPLEENOMEGALY

P:- 
TAB AZITHROMICIN 500 mg /PO/OD
TAB ULTRACET1/2tab /QID
TAB PANTOPRAZOLE 40 MG/PO/OD
INJ PIPTAS 4.5gm /IV/TID
TAB ZINCOVIT OD/PO
Vital monitoring
Temperature monitoring




Day 6
S :- 
Patient is having resting tremors
Pain at bone marrow biopsy site
Delayed speech
O:-
Pt is conscious, coherent cooperative

Bp:-120/80
Pr:-98 bpm
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender spleenomegaly
CNS:- NAD

A:-BICYTOPENIA UNDER EVALUATION(2 to malignancy infection) 
WITH
 COMMUNITY ACQUIRED PNEUMONIA WITH ESSENTIAL TREMORS WITH 
MODERATE HEPATOSPLEENOMEGALY

P:- 
TAB DOLO 650 mg /PO/OD
TAB ULTRACET1/2tab /QID
TAB PANTOPRAZOLE 40 MG/PO/OD
INJ PIPTAS 4.5gm /IV/TID
TAB ZINCOVIT OD/PO
Vital monitoring



Day 7

S :- 
Patient is having resting tremors
Altered behavior GCS E4V4M4
Involuntary Micturation
Fever spikes
Pain at bone marrow biopsy site
Delayed speech
O:-
Pt is conscious

Bp:-110/60
Pr:-130 bpm
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender spleenomegaly
CNS:- NAD

A:-BICYTOPENIA UNDER EVALUATION(2 to malignancy infection) 
WITH
 COMMUNITY ACQUIRED PNEUMONIA WITH ESSENTIAL TREMORS WITH 
MODERATE HEPATOSPLEENOMEGALY

P:- 
Riley's tube
Foleys catheter
IVF 3% Nacl at 10ml/hr
INJ MEROPENUM 1g IV STAT
INJ MEROPENUM 1g IV/BD
Temperature charting
Vital monitoring
Ryles feed



Day 8
S :- 
Patient is having resting tremors
Altered behavior
Fever spikes
Delayed speech

O:-
Pt is conscious

Bp:-130/70
Pr:-110 bpm
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender spleenomegaly
CNS:- NAD
Kerning sign positive

A:-BICYTOPENIA UNDER EVALUATION(2 to malignancy? infection? ) 
WITH
 COMMUNITY ACQUIRED PNEUMONIA WITH ESSENTIAL TREMORS WITH 
MODERATE SPLEENOMEGALY
ACUTE SYMPTOMATIC HYPONATREMIA 2 TO SIADH? 
ALTERED SENSORIUM 2 TO HYPONATREMIA? MENINGITIS? 

P:- 
Riley's tube
Foleys catheter
IVF 3% Nacl at 10ml/hr
INJ MEROPENUM 500 mg IV/BD
INJ OPTINEURON 1 AMP IN 100 ml NS/IV/OD
INJ NEOMOL 1 gm IV/SOS
TAB DOLO
Temperature charting
Vital monitoring
Ryles feed



Day 9
S :- 
Patient is having resting tremors
Altered behavior
Fever spikes
Delayed speech

O:-
Pt is conscious

Bp:-110/60
Pr:-120 bpm
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender spleenomegaly
CNS:- NAD
Kerning sign positive

A:-BICYTOPENIA UNDER EVALUATION
WITH PLASMA CELL DYSCRCIA
 COMMUNITY ACQUIRED PNEUMONIA WITH ESSENTIAL TREMORS WITH 
MODERATE SPLEENOMEGALY
ACUTE SYMPTOMATIC HYPONATREMIA 2 TO SIADH? 
ALTERED SENSORIUM 2 TO HYPONATREMIA? MENINGITIS? 

P:- 
Riley's tube
Foleys catheter
IVF 3% Nacl at 10ml/hr
INJ MEROPENUM 500 mg IV/BD
INJ OPTINEURON 1 AMP IN 100 ml NS/IV/OD
INJ NEOMOL 1 gm IV/SOS
TAB DOLO
Temperature charting
Vital monitoring
Ryles feed

DISCHARGE SUMMARY











Comments

Post a Comment

Popular posts from this blog

long case 2

Image
  This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.                                                                                      With the help of our senior https://mvineelarollno90.blogspot.com/2023/11/65-y-female-with-co-fever-since-4-days.html 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
Read more

Pathology

Image
CHRONIC LEUKEMIA By Munukutla Sai Mythili 88     Shwetha Mummadi 87 INTRODUCTION Leukemia is cancer that starts in the blood-forming cells of the bone marrow. When one of these cells changes and becomes a leukemia cell, it no longer matures the way it should and grows out of control. Often, it divides to make new cells faster than normal. Leukemia cells also don't die when they should. This allows them to build up in the bone marrow, crowding out normal cells. At some point, leukemia cells leave the bone marrow and spill into the bloodstream. This increases the number of white blood cells in the blood. Once in the blood, leukemia cells can spread to other organs, where they can prevent other cells in the body from functioning normally. Leukemia is different from other types of cancer that start in organs like the lungs, colon, or breast and then spread to the bone marrow. Cancers that start elsewhere and then spread to the bone marrow are not leukemia. What is a chronic leukemia? I
Read more

OSCE

Image
Hello everyone I'm mythili, an aspiring final year medical student presenting an osce report after garnering the patient informed consent Let's start off by learning the brief history about the patient A35 year old female came with cheif complaints of -Diminision of vision of right eye since morning 3am -Headache since 2 days Delving more into the history Patient was apparently asymptomatic 2 days back then started developing diffuse headache which was sudden in onset,gradually progressive associated with neckpain  No H/O nausea and vomiting,photophobia,phonophobia Then since morning 3am had sudden painless loss of vision No H/O ocular trauma or head trauma No H/O giddiness,LOC,weakness of both UL and LL No H/O fever,cough,cold,chestpain,palpitations,orthopnea,PND What was her last final diagnosis?  The final diagnosis  is CRVO Complete retinal venous occlusion  CRVO? How was the diagnosis made?  Upon opthological examination Dot blot hemorrhage Macular edema Which are characte
Read more