A 40 yr old female with severe anaemia
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A 40 yr old unmarried female c/o
Generalized weakness since 1yr
Decreased appetite since 1 yr
Bleeding PV since 4 days
She is a second born child of her parents ( 3rd degree consanguinous marriage)
Patient attained menarche at the age of 14, since then cycles were regular, with normal flow initially.
4-5 days /month, no clots, dysmenorrhea.
LMP- 05/02/2022
But since 6 months she has increased bleeding during her cycles.since 2 months her cycles was 10days /month associated with clots 2x2 cm, no pain.
No h/o burning mictuition, white discharge,. 6months back patient went to other private hospital where she was diagnosed with low Hb% and advised for blood transfusion which was not done and patient was not on any medication for anaemia.
Not a k/c/C/o DM, HTN, thyroid, epilepsy, asthma.
Appetite decreased since 2ys only 1 meal /day.
Pica +
Milestones - delayed and difficulty in learning.
General examination
Patient is c/c/c thin built and malnourished
Pallor ++,
no icterus, cyanosis, clubbing, edema
Temp-Afebrile
PR - 108bpm
BP-100/60 mmHg
Spo2 99%
GRBS - 87mg/dl
Frontal bossing, few hyperpigmented patches on face and crowded teeth +
Neck - diffuse goiter present
CVS
Inspection -
JVP raised
Apical impulse diffuse in 5th and 6th IC space
Palpation - thrills and para sternal haeve +
apex beat in mid clavicular line
Auscultation - loud S1 S2 + at pulmonary and tricuspid area , systolic, murmer +
CNS Examination
PT - c/c /c
Motor system
Tone - Rt Lt
U/L N N
L/L N N
Power
U/L 4/5 _ 4/5
L/L 4/5 _ 4/5
Reflex
Biceps 3+ 3+
Triceps 3+ 3+
Supinator 3+ 3+
Knee 3+ 3+
Ankle 3+ 3+
Plantar dorsiflexion
https://youtube.com/shorts/sujnx53d3v8?feature=share3
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.
RS - BAE +
P/A - soft NON-TENDER
Her outside reports were :
HB- 2.3%
Plt - 56,000
TLC - 7900
PCv - 8.2%
BGT - O +ve
Sr.cretinine- 1.4 mg/dl
Na+ - 139
CL - 96
K- 2.9
LFT
TB - 1mg/dl
DB - 0.2,ID - 0.8
ALT - 27, AST - 28
ALP - 114
TP - 6.9
ALB - 3.3
Investigations on 07/02/2022
ECG
Chest X ray
Usg
2D Echo
TB - 1.43
DB - 0.39
AST - 974
ALT 584
ALP - 66
TP - 5.2
ALB - 3.33,GLB - 1.95
RFT
Na- 140
K - 3.9
Cl- 103
Urea - 30mg /dl
Cr - 0.9 mg /dl
Thyroid profile
T3-0.6
T4-10.72
TSH-4.16
CBP -
HB- 1.7%
TLC - 13,100
N/L/E/M/B/- 81/06/03/10/0
PCB - 6.8%
MCV - 57.1
MCH- 14.3
MCHC-25
RDW-CV - 28
RDW - SD - 56.5
RBC - 1.19 MILLION
PLT - 74,000
PERIPHERAL SMEAR.
WBC - count increased, neutrophils show toxic granules
Impression - Microcytic hypochromic anaemia with neutrophilic leucocytosis and moderate thrombocytopenia.
LDH - 3027 IU/L
10/02/2022.
CBP
Hb-6gm%
TLC-7100
PLT-1.2lakh
RBC- 2.37 million
PCV-17.6
MCV-74.3
MCH-25.3
MCHC- 35.1
RDW-CV - 22.3
Imp- normocytic normochromic anaemia with mild thrombocytopenia
HIV, HBSAR, HCV - negative
LFT
TB-8.9
DB-3.12
ALT-297
AST-832
ALT-85
TP-5
GLB-3
A/G-1.5
PT-20 sec
INR- 1.4
APTT- 30sec
Serum iron-84mc g
Serum Ferritin - 25.6ng/ml
Coombs test - negative
2D ECHO on 11/02/2022
SECONDARY TO IRON DEFICIENCY /VIT B12 DEFIENCY WITH AUB UNDER EVALUATION
Rx
1.inj TRANEXA 500MG IV stat
2.inj pantop 40 mg iv/od
3.inj zofer 4 mg iv/sos
4. Plan for 1unit PRBC transfusion
5. Monitor vitals 4th hrly
6. I/o charting
Dar 2
9/02/2022
ICU Bed 4
Day 2
S:
Patient changed 2 pads yesterday
Bleeding P/V is as before
Appetite improved
O:
Patient is c/c/c thin built and malnourished
Pallor ++
no icterus, cyanosis, clubbing, edema
Temp-Afebrile
PR - 108bpm
BP-100/60 mmHg
Spo2 99%
GRBS - 87mg/dl
CVS
Inspection -
JVP raised
Apical impulse diffuse in 5th and 6th IC space
Palpation - thrills and para sternal haeve +
apex beat in mid clavicular line
Auscultation - loud S1 S2 + at pulmonary and tricuspid area , systolic murmer +
RS - BAE +
P/A - soft NON-TENDER
A:
Bicytopenia under evaluation
P:
1. 1 unit of PRBC transfused on Day 1 of admission
2.inj TRANEXA 500MG IV
3.inj pantop 40 mg iv/od
4.inj zofer 4 mg iv/sos
5. Monitor vitals 4th hrly
6. I/o charting
7.GRBS 6th hourly
CBP
HB-4gm%
TLC-9100
PLT-1.2 lakh
PCV-12.5
RBC-1.81 million
LFT.
TB- 3.52
DB- 0.84
ALT-725
AST-647
ALP-78
Tp- 5
Alb-2.04
A/g-0.69
BLOOD UREA-33
SR CREATININE-0.7
Serum electrolytes.
Na-142
K-3.1.
CL-101
10/02/2022
Day 3
S:
Patient changed 2 pads yesterday
Bleeding P/V is as before
Appetite decreased
O:
Patient is c/c/c thin built and malnourished
Pallor ++
no icterus, cyanosis, clubbing, edema
Temp-Afebrile
PR - 88 bpm
BP-90/60 mmHg
Spo2 99%
CVS
Inspection -
JVP raised
Apical impulse diffuse in 5th and 6th IC space
Palpation - thrills and para sternal haeve +
apex beat in mid clavicular line
Auscultation - loud S1 S2 + at pulmonary and tricuspid area , systolic murmer +
CNS Examination
PT - c/c non Co operative
Motor system
Tone - Rt Lt
U/L N N
L/L N N
Power
U/L 4/5 _ 4/5
L/L 4/5 _ 4/5
Reflex
Biceps 3+ 3+
Triceps 3+ 3+
Supinator 3+ 3+
Knee 3+ 3+
Ankle 2+ 2+
Plantar dorsiflexion
Cerebellar - ataxia present, rombergs positive
RS - BAE +
P/A - soft NON-TENDER
A:
HYPOPROLIFERATIVE MARROW ( BONE MARROW SUPRESSION
SECONDARY TO IRON DEFICIENCY /VIT B12 DEFIENCY
? SPINO CEREBELLAR ATAXIA
WITH AUB UNDER EVALUATION
P:
1.monitor vitals 2nd hrly
2.post transfusion reports awaited
10/02/2022.
CBP
Hb-6gm%
TLC-7100
PLT-1.2lakh
RBC- 2.37 million
PCV-17.6
MCV-74.3
MCH-25.3
MCHC- 35.1
RDW-CV - 22.3
Imp- normocytic normochromic anaemia with mild thrombocytopenia
HIV, HBSAR, HCV - negative
LFT
TB-8.9
DB-3.12
ALT-297
AST-832
ALT-85
TP-5
GLB-3
A/G-1.5
PT-20 sec
INR- 1.4
APTT- 30sec
Serum iron-84mc g
Serum Ferritin - 25.6ng/ml
Coombs test - negative
11/02/2022
Day 4
S:
Bleeding P/V decreased compared to yesterday, patient changed 1 pad yesterday
Appetite decreased, no
O:
Patient is c/c/c thin built and malnourished
Pallor ++
no icterus, cyanosis, clubbing, edema
Temp-Afebrile
PR - 82 bpm
BP-100/70 mmHg
Spo2 97%
CVS
Inspection -
JVP raised
Apical impulse diffuse in 5th and 6th IC space
Palpation - thrills and para sternal haeve +
apex beat in mid clavicular line
Auscultation - loud S1 S2 + at pulmonary and tricuspid area , systolic murmer +
CNS Examination
PT - c/c/c
Motor system
Tone - Rt Lt
U/L N N
L/L N N
Power
U/L 4/5 _ 4/5
L/L 4/5 _ 4/5
Reflex
Biceps 3+ 3+
Triceps 3+ 3+
Supinator 3+ 3+
Knee 3+ 3+
Ankle 2+ 2+
Plantar dorsiflexion
RS - BAE +
P/A - soft NON-TENDER
A:
HYPOPROLIFERATIVE MARROW ( BONE MARROW SUPRESSION
SECONDARY TO IRON DEFICIENCY /VIT B12 DEFIENCY WITH AUB UNDER EVALUATION
P:
1. Inj Methylcobalamine 1000mcg IV OD
2. monitor vitals 2nd hrly
12/02/2022
S:
Bleeding P/V decreased compared to yesterday
Appetite decreased.
O:
Patient is c/c/c thin built and malnourished
Pallor ++
no icterus, cyanosis, clubbing, edema
Temp-Afebrile
PR - 78 bpm
BP-100/70 mmHg
Spo2 97%
CVS
Inspection -
JVP raised
Apical impulse diffuse in 5th and 6th IC space
Palpation - thrills and para sternal haeve +
apex beat in mid clavicular line
Auscultation - loud S1 S2 + at pulmonary and tricuspid area , systolic murmer +
CNS Examination
PT - c/c/c
Motor system
Tone - Rt Lt
U/L N N
L/L N N
Power
U/L 4/5 _ 4/5
L/L 4/5 _ 4/5
Reflex
Biceps 3+ 3+
Triceps 3+ 3+
Supinator 3+ 3+
Knee 3+ 3+
Ankle 2+ 2+
Plantar dorsiflexion
RS - BAE +
P/A - soft NON-TENDER
A:
HYPOPROLIFERATIVE MARROW ( BONE MARROW SUPRESSION
SECONDARY TO IRON DEFICIENCY /VIT B12 DEFIENCY WITH AUB UNDER EVALUATION
P:
1. Inj Methylcobalamine 1000mcg IV OD
2. monitor vitals 2nd hrly
13/02/2022
Day 6
42 yr old female with bleeding PV
S:
Bleeding P/V decreased compared to yesterday
Appetite decreased.
O:
Patient is c/c/c thin built and malnourished
Pallor ++
no icterus, cyanosis, clubbing, edema
Temp-Afebrile
PR - 74 bpm
BP-100/70 mmHg
Spo2 96%
CVS
Inspection -
JVP raised
Apical impulse diffuse in 5th and 6th IC space
Palpation - thrills and para sternal haeve +
apex beat in mid clavicular line
Auscultation - loud S1 S2 + at pulmonary and tricuspid area , systolic murmer +
CNS Examination
PT - c/c/c
Motor system
Tone - Rt Lt
U/L N N
L/L N N
Power
U/L 4/5 _ 4/5
L/L 4/5 _ 4/5
Reflex
Biceps 3+ 3+
Triceps 3+ 3+
Supinator 3+ 3+
Knee 3+ 3+
Ankle 2+ 2+
Plantar dorsiflexion
RS - BAE +
P/A - soft NON-TENDER
A:
HYPOPROLIFERATIVE MARROW ( BONE MARROW SUPRESSION
SECONDARY TO IRON DEFICIENCY /VIT B12 DEFIENCY WITH AUB UNDER EVALUATION
P:
1. Inj Methylcobalamine 1000mcg IV OD
2. monitor vitals 2nd hrly
Ward
Day 7
42 yr old female with bleeding PV
S:
C/o abdominal distension, No bleeding PV
Appetite decreased.
O:
Patient is c/c/c thin built and malnourished
Pallor ++
no icterus, cyanosis, clubbing, edema
Temp-Afebrile
PR - 74 bpm
BP-100/70 mmHg
Spo2 96%
CVS
Inspection -
JVP raised
Apical impulse diffuse in 5th and 6th IC space
Palpation - thrills and para sternal haeve +
apex beat in mid clavicular line
Auscultation - loud S1 S2 + at pulmonary and tricuspid area , systolic murmer +
CNS Examination
PT - c/c/c
Motor system
Tone - Rt Lt
U/L N N
L/L N N
Power
U/L 4/5 _ 4/5
L/L 4/5 _ 4/5
Reflex
Biceps 3+ 3+
Triceps 3+ 3+
Supinator 3+ 3+
Knee 3+ 3+
Ankle 2+ 2+
Plantar dorsiflexion
RS - BAE +
P/A - abdomen distended
soft NON-TENDER
A:
1)Nutritional anemia (? IDA/B12 deficiency )
2) Ataxia secondary to ? B12 Deficiency /Sub acute combined degeneration of spinal cord.
3) Hyperdynamic heartfailure secondary to Severe Anemia with Severe PAH (? Idiopathic)
4) Small VSD
5) Diffuse goitre (euthyroid state )
P:
1. Inj Methylcobalamine 1000mcg IV OD
2. Tab Orofer Xt BD
3. monitor vitals 2nd hrly
USG - gross ascites
PLAN for USG guided tap
