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 










Comments

Post a Comment

Popular posts from this blog

Case-1

Image
 Aug 9,2021 Date of Admission-31-7-21 A 60 year old female presented to OPD with chief complaints of diffuse abdominal pain since 7-10days HISTORY OF PRESENT ILLNESS Patient was diagnosed in the nearest hospital 1 year back due to bloating of stomach. The Patient didn't undergo for the further treatment at that time. Patient was suffering from abdominal pain since a month ago and went to the nearest hospital. Test were performed and the reports shown that she is hypoglycemic, hyponatremic and CRP was extremely high about 92.7mh/l and serum creatinine level was 8.9mg/dl. She was refered then to KIMS for further treatment. She is undergoing dialysis(4) since then  She complains of hard stool and prescribed with liq paraffin and milk of magnesia syrup 10ml 3 times a day. She was hypovolemic and undergone blood infusion of 1 unit ( Blood group- B+) HISTORY OF PAST ILLNESS  No history of surgery, asthma, TB, CAD, epilepsy. PERSONAL HISTORY Decrease appetite  Bowel movement is irregular
Read more

Long case

Image
 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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. A 50 year old female is presented to OPD with chief complaints of shortness of breath and bipedal edema since 8 months. HISTORY OF PRESENT ILLNESS-: Patient was apparently asymptomatic 3 years back then she developed severe headache and went to nearest hospital and was diagnosed with hypertension. Patient developed shortness of breath 8 months back which aggrevated in supine position and also complain of pedal edema which is pitting in nature and gradually progressed then patient went to KIMS and was diagnosed with chronic kidney disease and she was on maintenance hemodialysis. She underwent two dialysis se
Read more

Short case

Image
 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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. A 50 year old male is presented to OPD with chief complaints of altered sensorium, fever and  vomitings since 5 days. HISTORY OF PRESENT ILLNESS  Patient was apparently asymptomatic 10 years back then he developed giddiness on routine check up and was diagnosed with diabetes. Patient had 4 months back injury to left foot with small ulcer which progressed and amputation of last 3 toes of the foot. 5 days back he went to brother's home as there was a party, he had mutton curry he skipped taking medication then behaviour of patient was abnormal and had a episode of vomiting which is non bilious and non pro
Read more