48 yrs female came to casualty with a complain of vomiting and giddiness.

20-03 -2022
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 patients clinical problems with collective current based inputs.

45 year old female who is a housewife survived with 3 kids came to casualty with 

C/O Vomitings ( food particle as content , non bilious , non projectile ) Since yesterday there were 10 episodes 

- C/O giddiness since 1 day 

History of presentillness:-

Patient was apparently assymptomatic 1 month back then she had decreased appetite since 1 month. 

- C/O weight loss since 1 month 

- C/O Shortness of breath ( grade 2 - grade 3 ) according to NYHA Classification, not associated with Orthopnea / PND since 15 days 

- H/O Heavy bleeding since 10 days (3-4 pads/day) 

- C/O B/L Pedal edema since 10 days 

Past History:-

- H/O similar complaints in the past diagnosed with megaloblastic anemia in the year 2017

- H/O Hemorrhoids in the year 2014

- H/O Recurrent Blood Transfusion since 2014

- Not a k/c/o DM/ HM/ Asthma / Epilepsy

Personal History :-

Married female 

Appetite - Decreased 

Diet :- mixed 

Bowels:- regular

Micturition:- normal 

- No addictions 

Family History :- Not significant 

General Examination :-

Patient is conscious , coherent , cooperative

- oriented to time , place , person

- Pallor +

- No icterus , clubbing , cyanosis , odema, lymphadenopathy 

Vitals :-

Temp:- 98.5 

PR:- 112/min

RR:- 18/min

BP:- 90/60mmhg

SPO2:- 99%

GRBS:- 105mg %

Systemic Examination :-

CVS:- S1S2 + PANSYSTOLIC Murmurs + Raised JVP

RS:- BAE + , No crepts 

P/A:- Splenomegaly + 

CNS:- Intact

Provisional Diagnosis :-

Anemia under evaluation 

 Megaloblastic anemia 

Investigations :-

Treatment :-

1) Inj METHYLCOBALAMINE 1500mcg in 50ml NS/ IV/ OD 

2) Inj TRANEXAMIC ACID 1 Amp IV/BD

3)  Tab ZOFER 4mg IV/ SOS

4). Inj NEOMOL 100ml ( if temp greater than 101.1 )

5)  Inj PAN 40mg IV/ OD

6)  Monitor Vitals Hrly


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