30 yr old male ,lorry driver by occupation

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.”


I've 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 a diagnosis and treatment plan.

CASE : 

 A 30 year old man,lorry driver by occupation,
resident of tangapally Choutupal came to the OPD with chief complaints of
- loose stools since one month 
- Fever since 20 days low grade,intermittent associated with chills
- yellowish discoloration of eyes since 20 days -weakness and loss of appetite SOB on exertion since 20 days

Patient is unmarried and chronic alcoholic since 10 years( 90 to 180 ml / day ) non smoker
 patient started binge drinking past 2 months after sister's marriage 
1 month ago patient only had binge intake (180 - 400 ml per day) for approximately two months without regular food intake in between 
patient even stopped going to work last intake was one month ago. patient is non-smoker due to financial issues and hard labour patient started binge drinking
 Since 1 month patient complains of loose stools 3 to 4 episodes which are watery occasionally black stools associated with pain abdomen in umbilicus
 associated with decreased urine output and burning micturition
Associated with fever - intermittent, low grade and associated with chills
 Yellowish discoloration of eyes + since 20 days fever associated with generalized weakness and loss of appetite and SOB on exertion grade 2 since 20 days 
No history of vomitings, pedal edema ,orthopnea and PND ,no palpitations
 History of blood donation 3 times

Past H/0 : 
No similar complaints in the past 
No history of any surgeries or blood transfusions
Not a K/C/O hypertension, diabetes,asthma epilepsy ,CVA ,CAD

Personal history : 
Diet - Veg 
Appetite - decreased 
Sleep - adequate
 Bowel movements - Loose stools +
Burning micturition
No known allergies
Chronic alcoholic since 10 years 
(Increased intake since past 2 months - 
180 - 400 ml only drinking the whole day without consuming food after his sister's marriage)
Stopped 1 month ago 

General examination : 

Pt is conscious, coherent,cooperative
Pallor +,icterus +,
No signs of cyanosis ,clubbing, lymphadenopathy,edema 
Dehydration +
Blackish discoloration of hands bilateral since 1 year
Tongue -dry and blackish discoloration +
Knuckle hyperpigmentation +
JVP +


Vitals : 

Temp : 98.7°F 
PR: 120 bpm
RR: 18
Bp: 100/60 
Spo2 : 98 % 

Systemic examination : 
CVS : S1,S2 Heard ,ESM +Aortic area and pulmonary area 
RS : BAE +,NVBS Heard 
P/A : Scaphoid abdomen , 
CNS : No FND 

Diagnosis : 
Pancytopenia  (?B12 deficiency secondary to chronic alcoholism )
Fever under evaluation (?osmotic /? infective diarrohea )


Investigations :

HEMOGRAM : 

Hb - 2.1 
TLC - 3500 
N/L - 55/42 
PLT - 40000
PCV - 5.9 
MCV - 109.3 
MCHC - 35.6

Anisopoikilocytosis with microcytes,macrocytes,macro - ovalocytes 

PT - 17 sec 
INR - 1.2 sec
APTT - 35sec
BT - 2min 30 sec 
CT - 5 min 00 sec 

BLOOD GROUPING AND RH TYPING : 

O POSITIVE 

Stool for occult blood : positive 

CUE : 
Albumin - trace 
Sugar nil 


Reticulocyte count : 0.4 %





Serology negative 
 

RFT 
urea -27
Creat - 0.8
Na -138
K - 4.1
Cl - 98

LFT : 
TB - 3.42
Db - 0.60
AST -12
ALT - 10
ALP - 139
TP - 5.7
Alb -3.4
A/G -1.5 

LDH - 884
 
RBS - 146 

Vit b 12 levels  - 377 

Serum Iron : 70 

Chest x ray : 



Coombs test : 

 

USG : 

2d echo : 


ECG : 





TREATMENT GIVEN : 
 
DAY 1 OF ADMISSION : 

S - Pt C/o loss of appetite and generalised weakness 

O - Pt is C/C/C
Temp: afebrile 
BP : 110/60 mmHg 
PR : 110/min
SPO2 : 98%
RR : 15 cpm
CVS : S1,S2 Heard ,ESM +Aortic area and pulmonary area 
RS :  BAE +,NVBS Heard 
P/A : soft,No organmegaly,BS+


A - Pancytopenia (secondary to ?B12 
?Bonemarrow suppresion 
-chronic diarrhoea under evaluation 
-chronic alcoholic 
-Hemolytic anemia with indirect hyperbilirubenemia )


P - 
1)Inj.vitcofol 1 amp 1000microgram/IM/daily for 1 week 
2)Inj.THIAMINE 2 amp in 100 ml NS /IV/TID
3)Inj.PAN 40 mg/iv/od
4)Inj.ZOFER 4 mg /iv/sos 
5)Tab.PCM 650 mg /PO/Sos
6)Inj.CEFTRIAXONE 1 gm/iv/bd 
7)Monitor vitals 
8)GRBS charting 

1 PRBC  TRANSFUSION WAS DONE .


DAY 2 OF ADMISSION : 

Hemogram : 
Hb - 3.3
Pcv - 9.4
Plt  - 15000
WBC - 3300

 Icu 2 Bed :

 30/M 

SUBJECTIVE : 

C/O Loss of appetite 
Generalised weakness 
One fever spike in the morning- 100F' 

OBJECTIVE: 



Pt. C/C/C 
BP : 100/50mm of Hg
PR : 80BPM 
CVS : S1, S2 + 
           ESM + in PA, Aortic area
RS : BAE + 
         Decreased B/S in Rt. Side ISA, IAA, IMA
         NVBS 
 P/A : Soft, Non tender 
           BS + 
  Stools : Passed ( Black) 3episodes,watery constistency    

 Stool for occult blood : positive 

stool for zn stain : no coccidian parasites observed 
fecal leucocyte count :no fecal leucocytes 





ASSESSMENT : 
Pancytopenia secondary to ? B12 deficiency 
? Bone Marrow Suppression
Chronic Diarrhoea under evaluation
Hemolytic anemia with indirect hyperbilirubinemia 

Plan of care : 
1. Propped up posture 
2. Inj. Vitcofol 1 amp 1000 microgram IM Daily for one week
3. Inj. Pan 40 mg IV/OD
4. Inj. Zofer 4 mg IV/SOS
5. Tab. PCM 650 mg PO/SOS 
6. Inj. Ceftriaxone 1g /IV/BD 
7. Vitals Monitoring 4th Hrly 
8. Strict I/O Charting 
9. GRBS 8 th Hrly

Day 3 of admission : 
Icu 

2nd bed 

Dr vaishnavi( pgy3)
Dr nikhitha(pgy3)
Dr raveen(pgy2)

SUBJECTIVE : 
 No fever spikes 
Passed 3 episodes of stools 
(1 episode - normal consistency ;2 episodes - watery ) 
No pain abdomen 

OBJECTIVE: 

Pt. C/C/C

Pallor + , Icterus +
Afebrile  
BP : 100/60mm of Hg
PR : 82BPM 
CVS : S1, S2 + ,flow murmur (systolic) in mitral area 
RS : BAE + ,NVBS 
 P/A : Soft, Non tender 
           BS + 
 
 Stool for zn stain : no coccidian parasites observed 
fecal leucocyte count :no fecal leucocytes 

 
ASSESSMENT : 
Pancytopenia secondary to ? B12 deficiency 
Chronic alcoholic
Chronic Diarrhoea (MALENA)
Indirect hyperbilirubinemia
S/P 2 PRBC transfusion I/v/o acute LV failure  

Plan of care : 

1. Inj. Vitcofol 1 amp 1000 microgram IM Daily for one week
2. Inj. Pan 40 mg IV/OD
3. Tab. PCM 650 mg PO/SOS 
4. Inj. Monocef 1g /IV/BD 
5. Vitals Monitoring 4th Hrly 
6. Strict I/O Charting 
7. GRBS 8 th Hrly

Day 4 : 

Icu

2nd bed 

Dr vaishnavi( pgy3)
Dr nikhitha(pgy3)
Dr raveen(pgy2)

SUBJECTIVE : 
 No fever spikes 
No loose stools
No pain abdomen 

OBJECTIVE: 

Pt. C/C/C

Pallor + , Icterus +
Afebrile  
BP : 110/60mm of Hg
PR : 84bpm
CVS : S1, S2 + ,flow murmur (systolic) in PA,MA
RS : BAE + ,NVBS 
 P/A : Soft, Non tender 
           BS +  

 
ASSESSMENT : 
Pancytopenia secondary to ? B12 deficiency bone marrow suppresdion secondary to
Chronic alcoholic
Chronic Diarrhoea (MALENA) secondary to UGIE bleed
Indirect hyperbilirubinemia

S/P 2 PRBC transfusion I/v/o acute LV failure  

Plan of care : 

1. Inj. Vitcofol 1 amp 1000 microgram IM Daily for one week
2. T. Pan 40 mg po/ od
3. Inj. Monocef 1g /IV/BD 
4.Vitals Monitoring 4th Hrly 
5. Strict I/O Charting 
6. GRBS 8 th Hrly


Day 5 :
Icu

2nd bed 

Dr vaishnavi( pgy3)
Dr nikhitha(pgy3)
Dr raveen(pgy2)

SUBJECTIVE : 
 No fever spikes 
No loose stools
No pain abdomen 

OBJECTIVE: 

Pt. C/C/C

Pallor + , Icterus +
Afebrile  
BP : 110/60mm of Hg
PR : 84bpm
CVS : S1, S2 + ,flow murmur (systolic) in PA,MA
RS : BAE + ,NVBS 
 P/A : Soft, Non tender 
           BS +  

 
ASSESSMENT : 
Pancytopenia secondary to ? B12 deficiency bone marrow suppresdion secondary to
Chronic alcoholic
Chronic Diarrhoea (MALENA) secondary to UGIE bleed
Indirect hyperbilirubinemia

S/P 2 PRBC transfusion I/v/o acute LV failure  

Plan of care : 

1. Inj. Vitcofol 1 amp 1000 microgram IM Daily for one week
2. T. Pan 40 mg po/ od
3. Inj. Monocef 1g /IV/BD 
4.Vitals Monitoring 4th Hrly 
5. Strict I/O Charting 
6. GRBS 8 th Hrly

Day 6 : 

30yr old male in ward 

SUBJECTIVE : 
No fever spikes 
No loose stools
No pain abdomen 

OBJECTIVE: 

Pt. C/C/C 

Pallor + , Icterus +
Afebrile  
BP : 120/70mm of Hg
PR : 82 bpm
CVS : S1, S2 + ,flow murmur (systolic) in PA,MA
RS : BAE + ,NVBS 
P/A : Soft, Non tender 
           BS +  


ASSESSMENT : 
Pancytopenia secondary to ? B12 deficiency bone marrow suppresdion secondary to
Chronic alcoholic
Chronic Diarrhoea (MALENA) secondary to UGIE bleed
Indirect hyperbilirubinemia 

S/P 2 PRBC transfusion I/v/o acute LV failure  

Plan of care : 
- Propped up posture 
- Inj. Vitcofol 1 amp 1000 microgram IM Daily for one week
- T. Pan 40 mg po/ od



Day 7 : 
30yr old male in ward 

SUBJECTIVE : 
No fever spikes 
No loose stools
No pain abdomen 

OBJECTIVE: 

Pt. C/C/C 

Pallor + , Icterus +
Afebrile  
BP : 120/70mm of Hg
PR : 82 bpm
CVS : S1, S2 + ,flow murmur (systolic) in PA,MA
RS : BAE + ,NVBS 
P/A : Soft, Non tender 
           BS +  


ASSESSMENT : 
Pancytopenia secondary to ? B12 deficiency bone marrow suppresdion secondary to
Chronic alcoholic
Chronic Diarrhoea (MALENA) secondary to UGIE bleed
Indirect hyperbilirubinemia 

S/P 2 PRBC transfusion I/v/o acute LV failure  

Plan of care : 
- Propped up posture 
- Inj. Vitcofol 1 amp 1000 microgram IM Daily for one week
- T. Pan 40 mg po/ od





Day 8 : 
Soap notes 

30yr old male in ward 

SUBJECTIVE : 
No fever spikes 
No loose stools
No pain abdomen 

OBJECTIVE: 

Pt. C/C/C 

Pallor + , Icterus +
Afebrile  
BP : 120/70mm of Hg
PR : 82 bpm
CVS : S1, S2 + ,flow murmur (systolic) in PA,MA
RS : BAE + ,NVBS 
P/A : Soft, Non tender 
           BS +  


ASSESSMENT : 
Pancytopenia secondary to ? B12 deficiency bone marrow suppresdion secondary to
Chronic alcoholic
Chronic Diarrhoea (MALENA) secondary to UGIE bleed
Indirect hyperbilirubinemia 

S/P 2 PRBC transfusion I/v/o acute LV failure  

Plan of care : 
- Propped up posture 
- Inj. Vitcofol 1 amp 1000 microgram IM Daily for one week
- T. Pan 40 mg po/ od



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