A 45YR OLD FEMALE DIAGNOSED WITH ANEMIA SECONDARY TO B12 DEFICIENCY

Diagnosis :
BAKER CYST ATROPHIC FUNDAL GASTRITIS ANEMIA SECONDARY TO B12 DEFICIENCY

 Case History and Clinical Findings:
 C/O SWELLING IN THE LEFT POPLITEAL REGION SINCE 3 MONTHS C/O PAIN OVER SWELLING SINCE 2 DAYS

 HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC3 MONTHS AGO THEN SHE DEVELOPED PAINLESS SWELLING IN THE LEFT POPLITEAL REGION WHICH INCREASED IN SIZE NOW MEASURING APPROXIMATELY C/O PAIN ASSOCIATED WITH SWELLING SINCE 2 DAYS SUDDEN IN ONSET,DRAGGING TYPE,NON RADIATING NO H/O FEVER NO H/O VOMITINGS,NAUSEA.

 PAST HISTORY: NOT A K/C/O DM,HTN,ASTHMA,TB,EPILEPSY,CVA,CAD 
H/O TONSILLECTOMY DONE 10 YEARS BACK 

GENERAL EXAMINATION: 
PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON. NO PALLOR,ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA. VITALS: TEMPERATURE:98.6
BP:120/80 MM HG PR:87 BPM RR:18 CPM 

SYSTEMIC EXAMINATION:
 CVS:S1,S2 HEARD NO MURMURS.
 RS:BAE +,NO MURMURS 
CNS:NO FOCAL NEUROLOGICAL DEFICITS. 

Investigation:
 HAEMOGRAM ON 9/12/2023 HB:4.6 TC:7590 PL:3.27 HAEMOGRAM ON 12/12/2023 HB:8.8 TC:8700 PL:1.59 FERRITIN 15.2 NG/DL 2D ECHO: MILD MR +/TRIVIAL TR +,NO AR NO RWMA,NO AS/MS GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION NO PAH/NO PE 

UPPER GI ENDOSCOPY :
 IMPRESSION;-ATROPHIC FUNDAL GASTRITIS ADVICED-BARIUM SWALLOW 

Treatment Given:
 INJ.IRON SUCROSE 100MG IN 100ML NS TAB.ZENTAL 400MG SYP.SUCRALFATE 0.2 TBSP BD TAB.PCM 650MG PO/TID TAB.PAN 40 MG OD
TAB.MVT PO/OD TAB.VIT C PO/OD TAB.ALBENDAZOLE 100MG PO/OD

 Advice at Discharge TAB.NEXPRO-L OD TAB.LIVOGEN 100MG OD 2 HOURS AFTER BREAKFAST X 3 MONTHS INJ.VITCOFOL 2CC IM ODX 7 DAYS FOLLOWED BY INJ.VITCOFOL 2CC IM ODX WEEKLY ONCE FOR 4 WEEKS.

DISCHARGE SUMMARY:

Diagnosis :
BAKER CYST ATROPHIC FUNDAL GASTRITIS ANEMIA SECONDARY TO B12 DEFICIENCY

 Case History and Clinical Findings:
 C/O SWELLING IN THE LEFT POPLITEAL REGION SINCE 3 MONTHS C/O PAIN OVER SWELLING SINCE 2 DAYS

 HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC3 MONTHS AGO THEN SHE DEVELOPED PAINLESS SWELLING IN THE LEFT POPLITEAL REGION WHICH INCREASED IN SIZE NOW MEASURING APPROXIMATELY C/O PAIN ASSOCIATED WITH SWELLING SINCE 2 DAYS SUDDEN IN ONSET,DRAGGING TYPE,NON RADIATING NO H/O FEVER NO H/O VOMITINGS,NAUSEA.

 PAST HISTORY: NOT A K/C/O DM,HTN,ASTHMA,TB,EPILEPSY,CVA,CAD 
H/O TONSILLECTOMY DONE 10 YEARS BACK 

GENERAL EXAMINATION: 
PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON. NO PALLOR,ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA. VITALS: TEMPERATURE:98.6
BP:120/80 MM HG PR:87 BPM RR:18 CPM 

SYSTEMIC EXAMINATION:
 CVS:S1,S2 HEARD NO MURMURS.
 RS:BAE +,NO MURMURS 
CNS:NO FOCAL NEUROLOGICAL DEFICITS. 

Investigation:
HAEMOGRAM ON 9/12/2023 HB:4.6 TC:7590 PL:3.27 HAEMOGRAM ON 12/12/2023 HB:8.8 TC:8700 PL:1.59 FERRITIN 15.2 NG/DL 2D ECHO: MILD MR +/TRIVIAL TR +,NO AR NO RWMA,NO AS/MS GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION NO PAH/NO PE 

UPPER GI ENDOSCOPY :
 IMPRESSION;-ATROPHIC FUNDAL GASTRITIS ADVICED-BARIUM SWALLOW 

Treatment Given:
 INJ.IRON SUCROSE 100MG IN 100ML NS TAB.ZENTAL 400MG SYP.SUCRALFATE 0.2 TBSP BD TAB.PCM 650MG PO/TID TAB.PAN 40 MG OD
TAB.MVT PO/OD TAB.VIT C PO/OD TAB.ALBENDAZOLE 100MG PO/OD

 Advice at Discharge TAB.NEXPRO-L OD TAB.LIVOGEN 100MG OD 2 HOURS AFTER BREAKFAST X 3 MONTHS INJ.VITCOFOL 2CC IM ODX 7 DAYS FOLLOWED BY INJ.VITCOFOL 2CC IM ODX WEEKLY ONCE FOR 4 WEEKS.

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