A 55 year old with c/o SOB on exertion since one month



























 Admission under unit 2 on 9/02/2021 


DR. YAMINI ( INTERN) 
DR. AMULYA ( INTERN) 
DR. SURYA PRADEEP ( INTERN) 
DR. ASHA KIRAN ( INTERN)
DR. JAYANTH ( INTERN) 
DR. VAMSHI ( INTERN)
DR. ISMAIL ( INTERN )
DR. PRADEEP ( PG 1st YEAR)
DR. CHANDANA ( PG 1st YEAR)
DR. NIKITHA ( PG 2nd YEAR)
DR. SUFIYA ( PG 3rd YEAR) 
DR. SATISH ( PG 3rd YEAR)
Faculty : DR. VIJAYALAXMI

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 also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome. Here is a case i have seen: 

55 year old male who is a cook came to opd with 
1. C/O SOB on exertion since one month
2. C/O generalised weakness since 15days
Patient was apparently asymptomatic 1 month back then he had gradual onset of SOB on walking over 500 meters. He gets sweating, giddiness, takes rest for 10min and again resumes his activity.
From 15 days, patient was not doing his routine activity of cooking because of weakness. Patient was using OROFER-XT 100mg  tablets OD and 1 iron sucrose inj/week for 3 weeks.
No H/O blood loss in stools, fever(-) vomitings(-) pedal edema(-) chest pain(-) palpitations (-)
Two years back, patient has pustules over chin, for which he consulted dermatologist. There, he was diagnosed as HIV(+) and started using ART( Dolutegravir + Lamivudine + Tenofovir dispro + fumavate)   On 21/8/2019 CD4 count was 99
Latest count: 400 ( 5 months back)
K/C/O DM2 and HTN since 10 years for which metformin 500mg, amlodipine 5mg and atenolol 50mg is given.
H/O loose stools for 3 months, stopped 1month back  after  treatment outside.
He had habits of smoking and drinking 
General examination: 
Patient is conscious coherent cooperative 
There are signs of pallor. 
No signs of icterus, cyanosis , clubbing, pedal edema





VITALS:
BP: 130/90 mmhg 
Pulse: 86/ min 
SpO2 at room air: 98% on RA 
RR: 18 cpm 
Systemic examination : 
CVS: S1 S2 heard 
CNS: no focal deficits 
RS: BAE + 
P/A: soft , NT
INVESTIGATIONS: 
CHEST X-RAY 

ECG: 

2D ECHO: 


USG ABDOMEN: 
HAEMOGRAM: 
B/G/T: 
FBS: 
PLBS: 
HBA1C: 
LFT: 
RFT: 
SERUM IRON: 
STOOL FOR OCCULT BLOOD: 


PROVISIONAL DIAGNOSIS: 
1. Anaemia under evaluation ( ? Megaloblastic anemia ) 
2. K/C/O RVD ( on treatment) 

TREATMENT: 
1. Inj. VITCOFOL 2ml/ IM/ weekly once 
2, Tab. PCM 650mg/ PO/ SOS 
3. GRBS monitoring 6th hourly premeals 
4. BP monitoring 4th hourly 
5. Continue ART regimen 

DAY-1 ( 10/02/2021) 
S- No new complaints no Fever spikes 

O- pt is conscious coherent 
BP- 140/80 mmhg 
PR- 78/ min 
GRBS- 150mg/dl 
CVS- S1 S2 heard 
RS- BAE + 
CNS- no focal deficits 
P/ A - soft NT 
A- anemia under evaluation ( ? Megalobalstic anemia)
K/C/O RVD ( on treatment) 
K/C/O DM2 And HTN 
With VENTRICULAR BIGEMINY 

P- 
Rx 
1. Inj. VIT B12 1000mcg / IM/ OD for 1 week 
2. Tab. PCM 650mg/ PO/ SOS 
3. GRBS monitoring 6th hourly 
4. Continue ART regimen 
5. T. TELMA - AM 40/5 mg / PO/ OD 
6. T. METFORMIN 500mg/ OD
7. T. METHICOBALAMINE 50mcg/ OD 
8. T. OROFER- XT / OD 
9. T. BACTRUM- DS - 800/160 mg /PO/ OD 
10. T. ALBENDAZOLE- 400mg/ PO/ STAT 

DAY- 2 ( 11/02/2021) 
S- No new complaints no Fever spikes 

O- pt is conscious coherent 
BP- 140/80 mmhg 
PR- 78/ min 
GRBS- 150mg/dl 
CVS- S1 S2 heard 
RS- BAE + 
CNS- no focal deficits 
P/ A - soft NT 
A- anemia under evaluation ( ? Megalobalstic anemia) secondary to ZIDOVUDINE? Nutritional 
K/C/O RVD ( on treatment) 
K/C/O DM2 And HTN 
With VENTRICULAR BIGEMINY 

P- Rx 
1. Inj. VIT B12 1000mcg / IM/ OD for 1 week 
2. Tab. PCM 650mg/ PO/ SOS 
3. GRBS monitoring 6th hourly 
4. Continue ART regimen 
5. T. TELMA - AM 40/5 mg / PO/ OD 
6. T. METFORMIN 500mg/ OD
7. T. METHICOBALAMINE 50mcg/ OD 
8. T. OROFER- XT / OD 
9. T. BACTRUM- DS - 800/160 mg /PO/ OD 
10. T. ALBENDAZOLE- 400mg/ PO/ STAT

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