Jasmi, morning dr randa.pptx
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A male patient presented with black stool for 4 days, nausea, fever, and increased breathlessness. His medical history includes diabetes treated with metformin, hypertension treated with captopril, and use of pain killers for 3 years. On examination, he had anemic conjunctiva, tachycardia, fast and shallow breathing, and cardiomegaly. Laboratory tests showed moderate anemia, acute kidney injury stage 1, and elevated inflammatory markers. He was diagnosed with melena due to NSAID-induced gastropathy, pneumonia, urinary retention post-cystostomy, and diabetes. Treatment included IV fluids, antibiotics, proton pump inhibitors, blood transfusion, and endoscopy was planned.
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This document summarizes the case report of a 20-year-old primigravida woman at 32 weeks of gestation who presented with severe anemia, breathlessness, giddiness and urinary tract infection. Her hemoglobin level was 3.3 g/dL. She was diagnosed with vitamin B12 deficiency induced pancytopenia and urinary tract infection. She received blood transfusions, intravenous vitamin B12 injections and antibiotics. Her condition improved with treatment and her hemoglobin rose to 7.9 g/dL.
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1. A 74-year-old man presented with continuous left upper abdominal pain for 3 days that worsened when lying on his left side. He had been fatigued for a year and was diagnosed with anemia.
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- Initial labs, ECGs, chest x-ray, and past medical records are summarized. Echocardiogram from last year showed LV hypertrophy and diastolic dysfunction. Coronary angiogram showed 3 vessel CAD.
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- 2. CC: black stool since 4 days ago, Present Illness History: Black stool since 4 days ago, changes diapers about 2-3x/day, unpleasant odor. Consumption pain killer drug for since 3 years ago but don’t know name of drug Nausea (-), vomiting (-) Breathlessness increased since 2 days ago, not influeced by activity, weather or food. Fever since 3 days ago. No high. No chill.Cough (-). Bleeding in another side (-) Patient was referred by RS Payakumbuh because of retention urine. After done surgical cistostomy, patient referred to internal departement for advance treatment.
- 3. History of DM (+), since 3 year ago. Drug: metformin , consumption regularly History of hypertension (+), since 10 year ago. Drug: captopril , consumption regularly History of gout (+), consumption pain killer Family Illness History No Family had symptoms like this patient.
- 4. Consciousness level :CM BP : 110/60 mmHg HR : 112 x/min, regular RR : 22 x/min, fast and shallow T :37,1 ºC Eyes : konjungtiva anemic (+) , sklera icteric(-), Neck : JVP 5-2 cmH2O. Lung : - Insp : symetric, static and dynamic - Palp : fremitus dextra = sinistra - Perc : Sonor Dextra = Sinistra - Ausk : bronchovesciculer, rhales (+/+), wheezing (-/-).
- 5. Heart Inspection: ictus is not seen Palpation: ictus is palpated at 1 finger lateral LMCS ICSVI Percussion: cardiomegali (+) Auscultation: regular rhytm, murmur (-) Abdomen - Insp : enlargement of abdomen (-), - palp : liver and spleen are not palpated - Perc : tympani - ausc : bowel sound (+) N
- 6. Extremities : oedem (-/-), Physiologycal reflex (+/+), pathological reflex (-/-).
- 7. Hb 6,3 Ht 19 L 12.390 Tr 186.000 PT/aPTT 1,18/31,6 Ur/kr 64/1,9 Na/K/Cl 138/4,3/112 RBG 139
- 8. Total Protein 5,2 gr/dl Albumin 3,2 gr/dl Globulin 2,0 gr/dl
- 11. Melena cb gastropathy NSAID Moderate Anemia Normocytic Normochrome cb acute bleeding DM type II diet controlled (metformin) Hospital Acquired Pneumonia Retentio urine cb BPH Post cystostomy Acute Kidney Injury St I cb Prerenal cb dehydration
- 12. Rest /Liquid diet 4x300cc/ O2 3litre/min IVFD NaCl 0,9% 8h/kolf Inj Cefepime 3x1 gr IV Inf Levofloxacin 1x500mg IV Inj. Prosogan 60 mg IV Drip prosogan 60mg in 500cc NaCl 0,9% finished in 8 hours inj.Transamin 3x500mg Inj.Vit K 3x1 amp
- 13. Metformin 3x500mg Sucralfate Syrup 3x10 cc PO Paracetamol 3x500mg PO Fluid balance Crossmatch PRC 2 Unit PRCTransfusion 2 Unit/day
- 14. Blood Gas Analysis EGD