19 year old female came with complaint of shortness of breath since 10 days.

History of present illness:

  • Patient was apparently asymptomatic 6 months ago when she experienced heavier flow in her menstrual bleeding.
  • She says, it has worsened in the last 3 months - where the cycles occur every 30 days and she bleeds for 5 days during which she has to use 10-15 pads a day for the first 2 days. 
  • She went the OB&G for the same and then was referred to General Medicine. 
  • She complains of shortness of breath on walking 4-5 steps, speaking and even eating food since the last 10 days associated with fatigue, weakness, palpitation and sweating. 
  • She gives a history of a severe episode of SOB today morning when she was packing to get to the hospital which subsided when the ASHA worker near their apartment made her sleep to the side, opened the windows and made her smell camphor. 
  • She complains of sudden breathlessness while in sleep at night, which subsides when she takes a stroll in the greens for around 5 minutes. This has happened intermittently and has occured more in the last 1 week. She also complains of slight difficulty in breathing while lying down - on being asked - but says it doesn't bother her much.
  • History of weight loss of 5 kg in the last 1 month. 
  • No history of fever, blood in stools, Hematemesis & Pedal Edema. 

History of past illness:

  • Patient was born to parents of a non-consanguinous marraige, through a FTNVD with weight 3.5 kg,  breastfed for 4 years and immunised as per universal immunisation schedule. 
  • When patient was  

  1. 5 y/o - Came to the hospital with SOB on walking; Was transfused 1 unit blood in Mirayalaguda.
  2. 10y/o - SOB leading to difficulty in walking / playing ; was diagnosed with hypothyroidism - prescribed 25ug Of Thyronorm - dose was gradually increased to 75 ug then 150 ug and then later decresed to 100ug over a period of time.
  3. 12y/o - Was brought to the hospital because she wasnt growing in height and was obese. Was admitted in KIMS Narketpalli. Was sent to KIMS LB Nagar where bone marrow biopsy was done. The result is not known as documentation is lost. Patient was given Calcium, Iron and Multivitamin supplements which she took for 2 months. Attained menarche 6 months later. 

Menstrual History:

  • Attained menarche at 14 years of age. 
  • 30/5 cycles. 
  • Pain is present
  • Clots are absent.
  • Uses 10-15 pads/ day in first 2 days of her period and. Then uses 2-3 pads/ days in the remaining days. 

Family history:

  • Grandmother h/o thyriod issue. 
  • No similar complaint in her sibling (Male - 1.5 years elder to her)

Treatment history:

  • Thyronorm
  • Calcium, Iron, and Multivitamin supplements

Personal History:

  • Diet - Mixed (prefers vegetarian food) 
  • Appetite - Normal
  • Sleep - Reduced since 10 days 
  • Bladder & Bowel movements - Regular

General Examination:

  • Patient is conscious, cohenrent and cooperative. Oriented to time, place and person. 
  • Pallor is present
  • Icterus/ Cyanosis/ Lymphadenopathy/ Pedal Edema/ Koilonychia are absent

Vitals:

  • BP: 90/60 mm of Hg 
  • Respiratory rate: 24 breaths per minute
  • Pulse rate: 80 beats per minute
  • Diffuse enlargement of Thyroid 
  • JVP Raised 
  • Knuckles hyperpigmented 
Hyperpigmented knuckles:

Little bit purpura, was initially red - now it's brown:


ECG:



Systemic examination:

Respiratory system examination:
  • Trachea Central 
  • BAE +
  • NVBS heard 
Cardiovascular system:
  • S1 S2 heard 
  • No mirmurs 
  • Carotid Bruit + 
  • Hyperdynamic apex 
Per Abdominal system:
  • Non Tender
  • Grade 3 Spelnomegaly (Spleen expanded uptill umblicus) 
  • Hepatomegaly - 
  • Liver span - Dullness on percussion from 6th ICS - 3 cm from rt costal margin
  • Bowel Sounds heard 
Central nervous system:
  • Higher Mental Function Normal 
  • NFND 

Provisional Diagnosis:

  • Anemia Under Evaluation 
  • ? Myelodysplastic Syndrome
  • ? Aplastic Anemia 

Plan:
  • Bone Marrow Aspiration
Investigations ordered:
1. Chest X Ray:


2. Ultrasound report:


3. Colour Doppler 2D Echo:


4. Hemogram:
( 7/7/21 )  Morning


5. Thyroid Function test: 
  • TSH - 61.33 micro lu/ml
  • T3 - 82.84 ng/m
  • T4 - 9.52 micro g/dl
6.LFT:
  • Total Bilirubin - 1.47
  • Direct Bilirubin - 0.66
  • SGOT - 58
  • SGPT - 22
  • ALP - 85
  • TP - 6.9
  • Albumin - 3.9
  • A/G - 1.6
7. Random Blood Sugar - 125 mg/dl

8. Hemogram:
( 7/7/21 ) Evening
  • HB - 4.1 gm/dl
  • TLC - 1800 cells/cmm
  • Neutrophils - 25 %
  • Lymphocytes - 70 %
  • Monocytes - 4 %
  • Eosinophils- 1 %
  • Basophils -0 %
  • Reticulocyte count - 0.7 %
  • HCT - 12 %
  • MCV - 129 fL
  • MCH - 44.1 pg
  • MCHC - 34.2 %
  • RDW-SD - 94.9 fL
  • RDW-CV - 23.3 %
  • RBC count - 0.93 millions /mm³
  • Platelet count - 36,000 lakhs/mm³
8. Blood smear:





  • RBC - Anisopoinitocytosis with microcytes,  macrocytes & Teardrop cells
  • WBC - Reduced on smear with lymphocytosis
  • Platelets - Reduced on smear
          Pancytopenia is seen.

9. SARS-COV-2 Qualitative PCR (8/7/2021)


10. AHG(COOMBS TEST ) (8/7/2021)


16. Bone marrow aspiration and peripheral blood smear ( 4/4/14 )

The patient had slides of the bone marrow aspiration and peripheral Smear which was done when she was 12 years old, these were reviewed,





Treatment:

Day1 ( 7/7/21 ) - 4:00 PM 

  • Tab . THYRONORM 150 mg OD
  • Tab. LASIX 40mg       1--0--1

DAY 2 ( 8/7/21 )

  • Tab . THYRONORM 150 mg OD
  • Tab. LASIX 40mg    1--0--1
  • Tab .OROFER XT BD    1--0--1
DAY 3 ( 11/7/2021 )
  • Tab . THYRONORM 150 mg OD
  • Tab. LASIX 20mg 1--0--1
  • Tab.Regestrone 10mg 1-1-1
  • Tab. PAUSE-MF 1-1-1
  • Inj.VITCOFOL IM/BD 1ml(500mg)
DAY 4 ( 12/7/21 )
  • Tab . THYRONORM 150 mg OD
  • Tab. LASIX 20mg 1--0--1
  • Tab.Regestrone 10mg 1-1-1
  • Inj.VITCOFOL IM/BD 1ml(500mg)
DISCHARGE SUMMARY 

Diagnosis:
  1. PANCYTOPENIA UNDER EVALUATION (/VITAMIN B12 DEFICIENCY /?HYPERSPLENISM)
  2. MODERATE SPLEENOMEGAY 
  3. HYPOTHYROIDISM 
  4. MENORRHAGIA 
Case history and Clinical findings:

CHIEF COMPLAINT - 19-YEAR-OLD FEMALE PRESENTS WITH SHORTNESS OF BREATH
FROM THE PAST 10 DAYS.

History of present illness:

  • Patient was apparently asymptomatic 6 months ago when she experienced heavier flow in her menstrual bleeding.
  • She says, it has worsened in the last 3 months - where the cycles occur every 30 days and she bleeds for 5 days during which she has to use 10-15 pads a day for the first 2 days. 
  • She went the OB&G for the same and then was referred to General Medicine. 
  • She complains of shortness of breath on walking 4-5 steps, speaking and even eating food since the last 10 days associated with fatigue, weakness, palpitation and sweating. 
  • She gives a history of a severe episode of SOB today morning when she was packing to get to the hospital which subsided when the ASHA worker near their apartment made her sleep to the side, opened the windows and made her smell camphor. 
  • She complains of sudden breathlessness while in sleep at night, which subsides when she takes a stroll in the greens for around 5 minutes. This has happened intermittently and has occured more in the last 1 week. She also complains of slight difficulty in breathing while lying down - on being asked - but says it doesn't bother her much.
  • History of weight loss of 5 kg in the last 1 month. 
  • No history of fever, blood in stools, Hematemesis & Pedal Edema. 

History of past illness:

  • Patient was born to parents of a non-consanguinous marraige, through a FTNVD with weight 3.5 kg,  breastfed for 4 years and immunised as per universal immunisation schedule. 
  • When patient was  

  1. 5 y/o - Came to the hospital with SOB on walking; Was transfused 1 unit blood in Mirayalaguda.
  2. 10y/o - SOB leading to difficulty in walking / playing ; was diagnosed with hypothyroidism - prescribed 25ug Of Thyronorm - dose was gradually increased to 75 ug then 150 ug and then later decresed to 100ug over a period of time.
  3. 12y/o - Was brought to the hospital because she wasnt growing in height and was obese. Was admitted in KIMS Narketpalli. Was sent to KIMS LB Nagar where bone marrow biopsy was done. The result is not known as documentation is lost. Patient was given Calcium, Iron and Multivitamin supplements which she took for 2 months. Attained menarche 6 months later. 

Menstrual History:

  • Attained menarche at 14 years of age. 
  • 30/5 cycles. 
  • Pain is present
  • Clots are absent.
  • Uses 10-15 pads/ day in first 2 days of her period and. Then uses 2-3 pads/ days in the remaining days. 

Family history:

  • Grandmother h/o thyriod issue. 
  • No similar complaint in her sibling (Male - 1.5 years elder to her)

Treatment history:

  • Thyronorm
  • Calcium, Iron, and Multivitamin supplements

Personal History:

  • Diet - Mixed (prefers vegetarian food) 
  • Appetite - Normal
  • Sleep - Reduced since 10 days 
  • Bladder & Bowel movements - Regular

General Examination:

  • Patient is conscious, cohenrent and cooperative. Oriented to time, place and person. 
  • Pallor is present
  • Icterus/ Cyanosis/ Lymphadenopathy/ Pedal Edema/ Koilonychia are absent

Vitals:

  • BP: 90/60 mm of Hg 
  • Respiratory rate: 24 breaths per minute
  • Pulse rate: 80 beats per minute
  • Diffuse enlargement of Thyroid 
  • JVP Raised 
  • Knuckles hyperpigmented 
Investigations:

1. Hemogram : HB- 4.5 gm/dlTC -2100 cells/cmmneutrophils -35 percentLymphocytes -60
percenteosinophils-1 percentmonocytes -4 percentbasophils -0 percentPCV- 13.6 volume
percentMCV- 129.5 flMCH-42.9 pgMCHC- 42.9 percentRBC count -1.05 millions /cummPlatelet count -80,000 /cummRBC- Anisopoikilocytosis with microcytes, macrocytes, and teardrop cellsWBC -
Reduced on smear with lymphocytosisPlatelet Count - reduced on smearPancytopenia

2.Thyroid Function test -TSH - 61.33 micro lu/mlT3-82.84 ng/mT4-9.52 micro g/dl3.

3. Random Blood Sugar- 125mg/dl

4.PROTHROMBIN TIME -14 secondsAPTT-30 seconds INR-1.0

5. LDH- 801 IU/L

6. LFT ;TotalBilirubin - 1.47 mg/dlDirect Bilirubin- 0.66mg/dlSGOT-58 IU/LSGPT -22IU/LALP-85 IU/LTP-6.4gm/dlAlbumin -3.9 gm/dlA/G 1.6

7.Reticulocyte count - 0.7 percent

8. Coombs ( direct and indirect ) negative.

9. Serum iron= 70 mcg/dl (50-170)

10. TIBC= 358 mcg/dl ( 215-535)

11. % Transferrin saturation =20% ( 13-45)

12. Serum ferritin = 59.4 ng/ml ( 4.63-204)

13. Vitamin B12= 117 pg/ml (211-911)

14. USG ABDOMEN - MODERATE SPLENOMEGALY (20CM)

15. 2D ECHO- RA/RV/LA- DILATED. MILD LVH PRESENT. EF=60%. IVC= 1.65 CM (DILATED).RVSP = 48MMHG. MODERATE TR WITH PAH. GOOD LV SYSTOLIC FUNCTION, NO DIASTOLIC DYSFUNCTION.

Advise at discharge:
  1. TAB. THYRONORM 150MCG OD
  2.  INJ. VITCOFOL (1ML = 500MCG) IM/BD FOR 5 DAYS F/B
  3. INJ. VITCOFOL (1ML=500MCG) IM/OD ON ALTERNATE DAYS FOR 1 WEEK F/B
  4. INJ. VITCOFOL (1ML=500MCG) OD ONCE IN A WEEK FOR 1 MONTH
  5. TAB. REGESTRONE 10MG TID FOR 3 DAYS
  6. F/B TAB. REGESTRONE 10MG BD FOR 5 DAYS
  7. F/B TAB. REGESTRONE 10MG OD FOR 5 DAYS.
  8. TAB. OROFER-XT OD FOR 1 MONTH.
















Comments

Post a Comment

Popular posts from this blog

BIMONTHLY BLENDED ASSESSMENT - JUNE 2021

BIMONTHLY BLENDED ASSESSMENT - JUNE 2021 -114 Sai Ajay Bompalli The following is a link to the assignment which has been given to me for a monthly progress evaluation: https://medicinedepartment.blogspot.com/2021/06/medicine-department-paper-for-june-2021.html?m=1 QUESTION 1: Please go through one particular answer of ten students in this link: http://generalmedicinedepartment.blogspot.com/2021/06/bimonthly-formative-and-summative_19.html?m=1  And share your peer review of each answer with your quantitative marking input as well as qualitative insights into what was good or bad about the answer.  ANSWER 1: After reviewing the pulmonology case in the following links: Link 1: https://aitharaveena.blogspot.com/   Qualitative: 8/10 Quantitative:  The symptomatology has been explained in a chronological order of occurrence but had missed the order for one of the symptoms. But the mechanism of action was very well explained with essential amount of information to explain the necessity of the
Read more
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-centred online learning portfolio and your valuable comments on 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 REPORT  A 43year old female, resident of Narketpalle came with the  chief complaints of: Generalised weakness since 15days Bilateral pedal edema since 15days HOPI:  Patient was app
Read more

A 70 year old Female with Neck - Muscle Stiffness and Loss of Speech

Image
A 70yr old female came with complaints of neck muscle stiffness and unable to speak. History of present illness:- Patient was apprently asymptomatic 7years back then she developed pain in the right shoulder for which she was managed conservatively 5years ago she developed weakness and giddiness and on evaluation was diagnosed with HYPERTENSION (started with TAB.ATENOLOL 25mg which she stopped 2months ago and started taking TELMA-40 as prescribed by local medical practitioner since the BP was’nt under control).Also since 5yrs she developed pain in both lower limbs for which she was prescribed TAB.ACECLOFENAC AND TAB.PREDNISOLONE-5mg by an RMP and stopped taking these from 2months. History of past illness:- Not a known case of DM,TB,Bronchial Asthma Personal history:- She takes mixed diet and has decreased appetite She has adequate sleep Her bowel and bladder movements are normal and regular Family history:- No significant family history Treatment History: TAB. ATENOLOL 5mg TELMA - 40  T
Read more