Chronic GE 2° to ?retroviral disease with severe anemia under evaluation(bicytopenia) with hypoalbuminemia

 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 : 

60 year old female came with c/o fever since 20 days
Vomitings since 20 days
Burning type of pain in the epigastrium since 20 days
Decreased appetite since 20days.

HOPI:
She was apparently asymptomatic 20 days back then developed fever which was insidious in onset,gradually progressive associated with chills and rigors subsided with medication
Vomitings since 20 days,non projectile, bilious,food particles as content 
Burning type of pain in the epigstrium not associated with nausea,non radiating
Loss of appetite since 20 days,
no h/o burning micturition,sob, dyspnea,chest pain,pedal edema,headache, cough,cold,giddiness,chest pain, palpitations.

Past history:
No similar complaints in the past 
Not a k/c/o DM,HTN, epilepsy,TB,asthma.

GE:pt. is c/c/c
Temp-Afebrile on touch 
PR-79bpm
BP-80/60mmhg
RR-18cpm
Spo2-98%
Pallor present

SE:
CVS-s1,s2 heard.
RS-b/l air entry present,NVBS heard
CNS-motor system normal
         Sensory system normal
         Cranial nerves intact
P/A-soft,non tender.

Investigations:

CBP-
   Hb:5.3
   TLC:3380
   Plt:75000

RFT-
  Urea:34
  Creat:0.7
  Uric acid:2.9
   Na:134
   K-3.0
   Cl-105

LFT-
  TB:0.68mg/dl
   DB:0.20mg/dl
   SGOT:59IU/L
   SGPT:46IU/L
   ALP:454IU/L
   TP:5.3gm/dl
   A/G ratio:0.24

Serology- 
HBsAG- negative 
HIV - reactive 
HCV antibodies- non reactive 

RBS-105mg/dl

ECG-


USG-

CXR-

Treatment:

Ivf-1 DNS, 1NS,1RL with 1amp optineuron @ 125ml/hr
Inj.pantop 40mg/iv/od
Inj.zofer 4mg/iv/od
GRBS 8th hrly
I/o charting strictly
Bp/pr/temp hrly 
Ors sachets 2sachets in 1lit water,200ml after each episode 
T.sporlac-ds od
Inj.noradrenaline 2amp in 50ml NS @2ml/hr 
Proteinex powder in 1glass of milk bd/po
3Egg whites/day 
T.bactrim ds 800/160mg bd trimethoprim+sulfmethoxazole)


Day 2:

O/e-
c/o one episode of vomiting after intake of fluids
c/o one episode of loose stools
Pt is c/c/c, severely malnourished,severe pallor +
Afebrile to touch 
Pr-76bpm
Bp-90/60mmhg
Grbs-134mg/dl
CVS-S1S2+
RS- BAE+, NVBS
P/A- soft ,NT

Investigations-

CBP- Hb-5.3
         Tlc-3500
          Plt- 80000

CUE-
Albumin- trace
Sugars-Nil
Pus cells- 6-10
Epithelial cells- 3-6
Red blood cells- 2-4
Casts -nil 
Bile salts-nil
Bile pigments-nil

Serum amylase-32IU/L

Reticulocyte count-1.5

Serum.ferritin-541.3ng/ml

Treatment-

Ivf- DNS @ 50ml/hr with 1amp optineuron
Oral fluids upto 2-4lit/day
Inj.pantop 40mg/iv/bd
Inj.zofer 4mg/iv/tid
Bp monitoring hrly 
Ors sachets 2sachets in 1lit water,200ml after each episode 
T.sporlac-ds bd
Proteinex powder 2table spoons in 1glass of milk tid/po
2Egg whites/day 
T.bactrim ds 800/160mg bd
trimethoprim+sulfmethoxazole)


Day 3: 
No fresh complaints
O/e- pt is c/c/c 
Afebrile on touch
Bp-80/50mmhg
Pr- 75bpm
Grbs-185mg/dl
I/o- 2100/1150ml
CVS-S1S2+
RS- BAE+, NVBS
P/A- soft ,NT

Investigations-

Spot urine protein - 7
Spot urine creatine - 12.5
Ratio- 0.56
BGT -B+ve

Treatment-

Ivf- DNS @ 50ml/hr with 1amp optineuron
Oral fluids upto 2-4lit/day
Inj.pantop 40mg/iv/bd
Inj.zofer 4mg/iv/tid
Bp monitoring hrly 
Ors sachets 2sachets in 1lit water,200ml after each episode 
T.sporlac-ds bd
Proteinex powder 2table spoons in 1glass of milk tid/po
2Egg whites/day 
T.bactrim ds 800/160mg bd

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