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A 60 year old female came to OPD 

With CHIEF COMPLAINTS Of-

Fever since 1 week

Palpitations since 1 week

Generalized weakness since 4 days

Chest pain and tightness since 4 days

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 1 week ago then she developed fever which is sudden in onset, high grade, associated with chills and rigor. It relieves temporarily on taking medication.

Palpitations are present since 1 week which are regular and associated with discomfort in the chest.

There is history of shortness of breath on exertion which is progressive. There is no orthopnea and paroxysmal nocturnal dyspnea.

This is associated with generalized weakness since 4 days and Blood in stools since 3 days.

There is no history of vomitings, loose stools, pain abdomen, giddiness.

PAST HISTORY

N/K/C/O Dm, Htn, Asthma, Tb, Epilepsy, CAD, CVA.

PERSONAL HISTORY

Mixed diet, normal appetite, sleep adequate, bowel and bladder movement regular, No addictions, No allergies.

GENERAL EXAMINATION 

Patient is conscious, coherent and cooperative and well oriented to time, place and person. 

No cyanosis, clubbing, lymphadenopathy and edema

Pallor present 

Icterus present 

Vitals on admission :

Temp - 98F 

BP - 130/70 mm hg 

PR - 98bpm 

RR- 22cpm 

Grbs - 131mg/dl 

SpO2 - 90% @ RA 

SYSTEMIC EXAMINATION 

CVS - S1 loud, S2 heard, JVP raised, systolic murmur present 

RS - trachea - central , bilateral air entry +, NVBS heard, no added sounds 

PER ABDOMEN - soft, non tender, hepatomegaly present, bowel sounds heard 

CNS - NFND 

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS

Megaloblastic Anemia.

TREATMENT:

27/11/23- 

1 unit PRBC Transfusion 

Inj Pan 40mg IV OD

Inj Iron sucrose 200mg in 100ml NS IV OD

Inj Vitcofol 1500mg in 100ml NS IV OD

Strict I/O charting, monitor vitals, inform sos 

28/11/23-

1 unit PRBC transfusion 

Inj Ceftriaxone 2g IV BD

Cap Doxycycline 100mg PO BD

Inj Pan 40mg IV OD

Inj Iron sucrose 200mg in 100ml NS IV OD

Inj Vitcofol 1500mg in 100ml NS IV OD

Strict I/O charting, monitor vitals, inform sos