36 year old man with pancytopenia

 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've seen:


A 36 year old man, who's a driver by occupation presented to the hospital with chief complaints of  breathlessness and palpitations on exertion since 1 month and decreased appetite since 4 days.



History of present illness:


The patient was apparently well 1 month back,then he developed breathlessness and palpitations on exertion,he also developed  easy fatiguability simultaneously for which he took medication on the advice of a Rmp. He also

gives history of decreased appetite from 4 days.

He observed losing weight from last 1 month.

He is also complaining of body pains since 15 days. Apprehended by his symptoms,he got his CBP done which showed decreased haemoglobin and all the cell counts. He presented to our hospital I/v/o blood transfusion.

No H/o fever,headache,nausea, vomitings,loose stools,malena,hematemesis,cough,burning micturion,syncopal attacks,trauma.


PAST HISTORY:

No similar complaints in the past.
H/o ? Anal fissure 15 years back
H/o surgery for DNS 10 yrs back.
No H/o HTN,DM, COPD, epilepsy, jaundice,TB,CKD, CHD
No H/o blood transfusions.

PERSONAL HISTORY: 

Diet: mixed
Appetite: decreased
Sleep: adequate
Bowel and bladder movements: regular.
Addictions: 
Occasional alcoholic since 20yrs (whiskey,90ml/day,once a month)

FAMILY HISTORY: 
No significant family history.

DRUG HISTORY: 
 Not allergic to any known drug

GENERAL EXAMINATION: 

Patient is conscious, coherent and cooperative

Moderately built and moderately nourished.
Signs of Pallor ++
No signs of icterus, cyanosis , clubbing, koilonychia, generalised lymphadenopathy, bilateral pedal edema.
 
VITALS:
Temperature: afebrile
Pulse rate:  68 bpm,regular
BP: 110/90 mm of hg
RR: 18cycles per min.
Sp02 : 98% at room temperature
GRBS: 114 mg/dl

SYSTEMIC EXAMINATION:

PERABDOMINAL EXAMINATION
 Inspection - 
Shape of abdomen: oval
Umbilicus - central
All quadrants are moving equally with respiration
Hernial orifices- free
No visible peristalsis
No engorged veins ,no sinuses and scars

Palpation - 
No local rise of temperature 
 Soft and non tender
No palpable masses.
No guarding and rigidity.
No free fluid 
Liver and spleen : not palpable.

Percussion - 
Tympanic note

Auscultation - 
Bowel sounds: normally heard and no bruit.
 
RESPIRATORY SYSTEM:
Position of trachea: central
No wheeze and dyspnea.
Bilateral air entry present.
Normal vesicular breath sounds heard.
No adventitious sounds.

CVS:
S1 and S2 heard.
No murmurs.

CNS:
Higher mental functions normal
All cranial nerves intact

Based on the clinical findings,the following investigations were sent:

Hemogram
Peripheral smear

Absolute reticulocyte count - 0.3
Reticulocyte index - 0.15
Impression: HYPOPROLIFERATIVE BONE MARROW

Vit B12 & folic acid levels
Coombs test(direct & indirect) - negative
LFT 
ECG
USG abdomen - no splenomegaly
Blood grouping and Rh typing - O-ve
AEC
PT,aPTT
Serology- negative
FUNDOSCOPY- ? Anemic retinopathy











Peripheral smear -
RBC :moderate anisopoikilocytosis showing predominantly macrocytes,macroovalocytes along with microcytes,tear drop cells and pencil forms,
3 nRBC/100 WBC
WBC: Total count decreased,many hypersegmented neutrophils seen.
PLATELETS:reduced on smear,few giant platelets seen
No haemoparasites on present smear

Impression:

Dimorphic anemia with predominantly macrocytic anemia with leucopenia and thrombocytopenia.

 Image showing  Tear drop cells,pencil forms,microcytes and macroovalocytes

Hhypersegmented neutrophils




      






After transfusing 1 unit of pRBC






Diagnosis:

Pancytopenia  secondary to Vitamin B 12  and folate deficiency with ? Hemolytic picture

Treatment:
1. Plan for blood transfusion
2.T.DOLO 650 MG TID
3.INJ VIT B12 1000mcg IN 100 ML NS OD
4.INJ VITCOFOL 2 cc (alternate day)
5.T.FOLATE 2.5 MG OD
6.T.OROFER XT OD
7.T.ALBENDAZOLE 400MG STAT
8.eye drops NEPATOP TID




Comments

Post a Comment

Popular posts from this blog

75 year old woman with Renal pathology since 5 yrs, gluteal abscess -6 yrs ago with recent GE & Oliguria

Image
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've seen: A 75 year old female who's a farmer by occupation, a resident of a village nearby, presented to the hospital 5 days back with chief complaints of decreased urine output a/w burning micturition since 15 days and  SOB since 7 days. HOPI The patient was apparently asymptomatic 15 days back,then she noticed decrease in her urine output a/w burning micturition. 10 days back, she had epigastric pain a/w Vomitings(2-3 episodes/day,  nonbilio
Read more

GM

  Anatomical diagnosis -? Glomerulosclerosis                                                                        Etiological diagnosis -  ? Nephrotic syndrome secondary to diabetic nephropathy/ CKD.     2)Reasons for  I)Azotemia : impaired renal excretion of urea and creatinine secondary to CKD.  II) Anemia : decreased erythropoietin.  III) Hypoalbunemia:due to damage to capillary basement membrane and podocytes.  IV)  acidosis: acidification of urine is lost.                                       3) Rationale : syrup potchlor was given to correct hypokalemia. Inj. NaHCO3 was given for metabolic acidosis.Insulin and antihypertensives are given because of known case of DM and HTN. T.Orofer XT was administered to treat anemia.. Inj. Lasix was given to decrease her volume overload. Spironolactone was given as it is a potassium sparing diuretic.Calcium was given to the patient  because of hypocalcemia secondary to CKD.  Indications of NaHCO3:metabolic acidosis in cardiac arrest, Tricycl
Read more

60 year old woman with Right sided Hemiparesis

Image
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've seen: A 60 year old woman was brought to the hospital by her daughter 1 day back with the chief complaint of sudden onset weakness of upper & lower limbs since 2 days. History of present illness: The patient was apparently asymptomatic 2 days back,then developed  sudden onset weakness of limbs( Rt > Lt )followed by tingling sensation and numbness of lower limbs,which progressed to upperlimbs, non progressive,lasted for 2-3 hrs, then reco
Read more