PANCYTOPENIA UNDER EVALUATION

11/5/21

Intern:G.Ramya

PG-YI: Sai Charan 

PG-YII:A.Vaishnavi

Faculty on call:Dr.Vijayalakshmi

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."

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

Case:

A 36 y/o female,seed packer,resident of Nalgonda came to the OPD with the chief complaints of 

-B/L pedal edema since 5 days 

-Facial puffiness since 5 days 

-SOB on exertion since 5 days 

History of presenting illness:

Patient was apparently normal 5 years back,then she developed menorrhagia for 6-7 days changing 3-4 pads/day associated with clots for which they consulted a General Physician and was told that she has anemia with reduced Hb,platelets and WBC's following which she had 1 PRBC transfusion. Now,she presented to OPD with C/O pedal seem A,pitting type,extending upto knee associated with facial puffiness 

SOB -Grade II,gradual onset ,progressive in nature ,not associated with sweating,chest pain,palpitations

History of past illness: 

Not a k/c/o HTN,DM,BA,CAD,EPILEPSY,TB

Previous history of blood transfusion-5 years ago;no reactions 

Personal history:

Marital status:Married 

Occupation: Packs seeds in a factory 

Appetite:Normal ,non-veg

Bowels:Constipation,alternate days 

Micturition:Normal

Allergies:No

Habits-Occasional drinker : Toddy and beer,once every few months,last drink was a year ago

Family history:

No similar history in the family 

Low socio-economic status 

No significant family history 

General examination: 

Patient is conscious,coherent and co-operative. 

Alert and oriented to time,place and person. 

Thin built and nourished 

Pallor +

Pedal edema + 

Flat nails +

No signs of icterus,cyanosis,clubbing,koilonychia,lymphadenopathy

 JVP: Not raised

VITALS: 

Temperature: Afebrile 

PR:86 bpm

RR:14 cpm

BP:100/50 mm If

SPO2: 99 % at RA

GRBS: 103 mg %

Local examination: 

CVS

Inspection : -

- Shape of the chest normal , symmetrical ,no deformity 

-Trachea appears to be central ,no precordial bulge 

- No visible pulsations or engorged veins

Palpation : 

-All inspectory findings confirmed by palpation   

-Trachea is central 

-Apex beat is felt at 5th intercostal space

-No  pericardial rub 

Percussion :  

-No dull note noticed.

 Auscultation : 

-S1 S2 heard

Respiratory system :

-Bilateral air entry present 

-Normal vesicular breath sounds heard ,no added sounds

Per abdomen :

-Soft,non-tender

-Mild splenomegaly

-Bowel sounds heard 

-Hernial orifices are normal 

CNS:

-Conscious 

-Normal speech 

- No signs of meningeal irritation 

Cranial nerves,motor system,sensory system,GCS-NAD

Investigations:

CXR-PA view

ECG

2D Echo

Usg-Abdomen

Peripheral smear

Under 10 xUnder 40x high power field

Under 100 x

Peripheral smear:

RBC(R):Anisopoikilocytosis with hypochromia with 

microcytes,Normocytes,tear drop cells 

WBC:Reduced on smear 

Platelets (P):Reduced on smear 

Neutrophils (N)

Impression:Pancytopenia

Provisional diagnosis:

PANCYTOPENIA UNDER EVALUATION WTIH DILATED RA AND IVC

Treatment:

Tab. Livogen 150 mg

Monitor vitals