22/F , Pancytopenia

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Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect current best evidence based input

This Elog also reflects my patient centered online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever ."

Case history:

22yr old female came to opd with complaints of Easy fatiguability,Loss of appetite,Shortnessof breath since past 1 year

Patient was apparently asymptomatic 1year ago then she developed fatigue (easy fatiguability) , loss of appetite , c/o shortness of breath since 1year ( Grade-lll MMRC) insidious in onset,gradually progressive,c/o palpitations , c/o black coloured stools 3 days ago

No H/O Orthoptera/PND 

No c/o chest pain, pedal edema

No bleeding manifestations

No drug overdose

No c/o fever,cold,cough,vomitings

No c/o weight loss

N/K/C/O HTN/DM//TB/Thyroid disorders/asthma/Epilepsy/CVD/CAD 

H/O Blood transfusion - 1 Episode(c/o vomitong after 1hour of blood transfusion)

H/O Jaundice - 1year ago

Diet:mixed,Appetite:decreased,sleep:reduced,bowel & bladder: regular,addictions:nil

Menstural H/O:3/28,regular cycle,changes 3-4 pads per day,no passage of clots

General Examination showed thin built,pallor,yellowish discolouration of bulbar conjunctiva ,round scar around umbilicus,hyperpigmentation on tongue,erosions of tooth present

Moderate splenomegaly

lungs clear and Apex beat  localised to 5th intercoastal space with RV heaving

P/A: soft in epigastric region

Spleen - palpable 5 cm below it’s coastal margin,splenic notch felt

Palpable liver ,liver span -15cm

No focal deficits in neurological examination

GENERAL EXAMINATION:

Initial investigations revealed:

HAEMOGRAM

Haemoglobin - 6.1 gm/dl

RBC Count : 3.5 million/cumm

WBC Count: 1900 cells/ cumm

PCV/HCT : 24.7%

MCV : 70.6 fL

MCH : 17.4 pg

MCHC : 24.7 gm/dl

Platelet count: 48,000 cells/ cumm

Neutrophils:64%

Lymphocyts:27%

Eosinophils:04%

Monocytes:05%

Basophils:0%

SMEAR:

Mild Anisopoikilocytosis showing Microcytic Hypochromic RBC’s admixed with Normocytic Normochromic RBC’s with Occasional Pencil forms

TC is decreased ,DC is within normal limits,No abnormal/ immature cells 

Platelets decreased

No hemoparasites seen 

IMPRESSION : PANCYTOPENIA

LIVER PROFILE:

Total bilirubin:1.6mg/dl

Direct bilirubin:0.7 mg/dl

Alkaline Phosphatase: 137U/L

ALT:128U/L

AST:98IU/L

Total protein:6.7g/dl

Albumin:3.8gm/dl

Globulin:2.9gm/dl

RENAL FUNCTION:

Blood Urea:12mg/dl

Serum Creatinine:0.3mg/dl

Sodium-141mEq/L

Potassium-4.1mEq/L

Chloride-106mEq/L

Calcium-1.10mmol/L

BLOOD GROUP - B POSITIVE

DIRECT COOMBS TEST - NEGATIVE

THYROID PROFILE

T3#0.78

T4#11.9

TSH#3.63

URINE EXAMINATION

Volume#15ml

Colour#yellow

Appearance# slightly turbid

PH#6.0

Specific gravity#1.020

Protein#nil

Glucose#nil

Pus cells # 1-2/hpf

Epithelial cells#4-6/hpf

No RBC cells, casts,crystals

STOOL FOR OCCULT BLOOD : NEGATIVE

ULTRASOUND

E/o dilated portal vein diameter~13mm

E/o perisplenic collaterals noted ( splenic vein diameter~ 13mm)

E/o moderate splenomegaly

IRON PROFILE

Serum iron#24

UIBC#352

TIBC#376

Serum ferritin#325

Reticulocyte count : 7%

On Examination: 

She was thin built

Height-140cm

Weight:30kg

Anemia +,Icterus+

DAY 1

1.Inj:Meaxon plus1 ampoule in 100ml NS IV/OD

2.Tab.livogen150mg PO/OD

3.Tab.Limcee 500mg PO/OD

DAY 2

1.Inj.Meaxon plus 1ampoule in 100 ml NS IV/OD

2.Tab.livogen150mg PO/OD

3.Tab.Limcee500mg PO/OD

DAY 3

1. Inj.Meaxon plus 1 ampoule in 100ml NS IV/OD

2.Tab.livogen150mg PO/OD

3.Tab.Limcee500mg PO/OD

DAY 4

1.Inj.Meaxon plus 1ampoule in 100ml NS IV/OD

2.Tab.livogen150mg PO/OD

3.Tab.Limcee500mg PO/OD