Case-3

 September 7, 2021

Date of Admission- 4-9-21

A 70 year old male presented to OPD with chief complaints of shortness of breath, tired on walking for short distance since 20 days

HISTORY OF PRESENT ILLNESS 


History of blood transfusion 10 days back at suryapet (4 units given)

History of red color urin after transfusion,fever for 2 days

History of left leg wound due to trauma, 3 months back

No history of cough,blurring of vision


HISTORY OF PAST ILLNESS 

No history of  diabetes, asthma, CAD, hypertension, tuberculosis, previous surgery, previous radiation 


PERSONAL HISTORY 

Diet-Mixed

Appetite-Normal

Bowels-regular

Sleep-normal


FAMILY HISTORY 

No history of hypertension, diabetes, heart disease, asthma,cancer


GENRAL EXAMINATION 

Patient is conscious,coherent, co-operative and well oriented to time and place 

There is sign of pallor,oedema of left foot

There is no sign of cynosis,lymphadenopathy 


VITALS

Temperature-afebrile

Pulse rate - 90bpm

Respiratory rate-normal 

BP-110/70

SPO2-98%


SYSTEMIC EXAMINATION 

Thrills-No

Cardiac sound-S1,S2

Cardiac murmer-No

RESPIRATORY SYSTEM 

Dyspnoea-No

Wheeze-No

Position of trachea-Central

Breath sounds-Vesicular

ABDOMEN 

Shape of abdomen-scaphoid

No tenderness 

No palpable mass

No Free fluid 

CENTRAL NERVOUS SYSTEM 

Patient is conscious 

Speech-normal

Motor and sensory system-Normal


PROVISIONAL DIAGNOSIS 

Pancytopenia Decreased evaluation 

INVESTIGATION 

Haemogram- 4-9-21


Hemoglobin-3.7

Total count-2800

Neutrophils-21

Lymphocytes-71

Eosinophils-02

Monocytes-06

Basophils-00

PCV-11.0

MCV-98.2

MCH-33.0

MCHC-33.6

RDW-CV-21.1

RDW-SD-69.3

RBC COUNT-1.12

PLATELET COUNT-10000


SMEAR

RBC- Anisopoiliocytosis with hypochromia microcyst,microcyst,macroovalocytes and few normocytes

WBC-reduced on smear with lymphocytosis

PLATELETS- reduced on smear

HAEMOPARASITES-No haemoparasites seen

IMPRESSION-Pancytopenia

LIVER FUNCTION TEST- 4-9-21

Serum iron
LDH
Reticulated count



TREATMENT 

Inj. Methylcoblamine 100 microgram/IM/OD

Inj. Iron sucrose 
1amp in 100ml NS/IV/OD after test dose

Vital monitoring 










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