Hello all , I’m an intern and here is a case history of one of our patients who got admitted .
This is to complete my log book as a part of my internship duty.
11/04/2020
A 47 year old female presented to OPD with complaints of
Difficulty in breathing since 10 days not aggravated or relieved with positional or diurnal variation
palpitations since 10 days which were short lasting
Bilateral pitting type of edema of lower extremities since 10 days
No h/o pain or warmth at the local sites of edema , no color change
No h/o facial puffiness or abdominal distention.
She is a known hypertensive pt since 20 years .
she is on medication tab . Telmisartan 20mg daily
H/o filariasis in rt lower limb since 15 years and is using medication DEC 100 mg for 2 weeks in a year.
On general EXAMINATION
Pt was c/c
Temperature:96.5 F
Bp:130/90mm Hg
Pulse:84 bpm
Spo2: 99%
CVS: S1 S2 heard
RESPIRATORY SYSTEM: b/l normal vesicular breath sounds
P/A: shape of the abdomen: obese
No free fluid ,scars ,sinuses
Hernial orifices normal
No tenderness
Liver is palpable 2-3 cms
Spleen is palpable- 4 cms
Bowel sounds present
CNS: HMF intact
Speech normal
Sensory system normal
Motor system normal
INVESTIGATIONS
Hemogram: On presentation she had hb-4.5 gm/dl .
After
1 st blood transfusion On12/05/20 hb:6.2 gm/dl
Total count:14,200 cells/cumm
Pcv:18.3 vol
Rbc:1.96 millions/cumm
Platelet: 1.01 lakhs/cumm
After 2 ndblood tranfusion
On 15/05/20 hb: 9gm/dl
Pcv:28.6 vol%
Mchc:31.3%
Rdw-cv 19.5%
Serum iron- 40ug/dl
Serum ferritin- 109ng/ml
Rft: urea- 10mg/dl
Sodium-139mEq/l
Potassium-4.1mEq/l
Chloride-104mEq/l
Lft:Total bilirubin-1.28mg/dl
Direct bilirubin-0.52mg/dl
SGOT-24IU/L
SGPT-12IU/L
Alkaline phosphate- 118IU/L
Total proteins - 5.7gm/dl
Albumin-3.7gm/dl
Blood smear picture :
RBC:hypochromic with anisopoikilocytosis comprising normocytes ,macrocytes ,tear drop cells,schistocytes, ,polychromasia and nucleated rbcs 2-3 / 100 wbc
WBC: normal count with hypersegmented neutrophils and mild shift to left
Platelets: adequate
No parasites
Impression: normocytic hypochromic anemia with hypersegmented neutrophils
-? Megaloblastic anemia
-? Hemolytic anemia
Osmotic fragility-lysis starts at 0.45%
Completes at 0.33%
Stool culture: no pus cells,no rbcs, no parasitic forms of ova / cyst seen
Stool for occult blood: positive
Serology is negative
Direct coombs test negative
Indirect coombs test POSITIVE
USG abdomen-splenomegaly
Fibroid uterus
Right hydrosalpinx
2d echo: mild dilated R.A/ R.V
PROCEDURE LEARNT: BONE MARROW ASPIRATION ( site- sternum) done on 13/05/20
First consent was taken from the patient for the procedure and the pt didn’t agree for video recording of the procedure. Then the patient was given a test dose of xylocaine. After half and hour at the level of 2 nd intercoastal space 10ml xylocaine was given then marrow was Aspirated.
Report: reactive marrow with erythroid hyperplasia
DIAGNOSIS:
?megaloblastic anemia
?hemolytic anemia
TREATMENT GIVEN:
Planned for 2 prbc blood transfusion
Inj. Vitcofol 2cc/im/od (D 3/5)
T.livogen 150mg/po/od for 1 month
T.MVT/po/od
Inj methylcobalamine 1 amp/im/od 500 mcg for 5 days (D1/5)
ADVICE AT DISCHARGE:
Inj. Hydroxocobalamin 1000 mcg for 3 days. Followed with weekly once for 1 month. Later on monthly once for 2 months
T. MVT po od for 1
Topic learnt today : myelodysplastic syndrome
(MDS)Myelodysplastic syndrome is a clonal hematopoietic stem cell disorder characterised by morphological dysplastic changes in one or more of major hematopoietic cell lines.
MDS can be presented with cytopenias - neutropenia, anemia and thrombocytopenia.
FAB classification was recommended early and as modified by WHO .
WHO uses percentage of blasts in bone marrow, ring sideroblasts and dysplastic changes to differentiate MDS subtypes.
1. Refractory anemia
2.refractory anemia with ringed sideroblasts
3. Refractory cytopenia with multilineage dysplasia
4. Refractory cytopenia with multilineage dysplasia and ringed sideroblasts
5.refractory anemia with excess blasts
6.myelodysplastic syndrome unclassified
7. MDS with isolated del (5q)
Some of the cytopenic causes are:
A.Chronic liver disease
B.drug induced cytopenia
C.excessive alcohol intake
D.b12/folate deficiency
E.autoimmune cytopenia
F. Anemia of chronic disorders
G . Parasitic infections
Stem cell disorders like IDUS,ICUS ,CCUS,CHIP
Intext source https://www.intechopen.com/books/recent-developments-in-myelodysplastic-syndromes/diagnosis-and-classification-of-myelodysplastic-syndrome
Clinical presentation : infection,bleeding/bruising ,gum bleeding,petechiae
Symptoms include general weakness, pallor,shirtness of breath
On physical examination enlarged spleen size.
Investigations : complete blood picture,serum ferritin, serum iron,stool culture,2d echo,USG abdomen, bone marrow aspiration.
Dysplastic changes include :
Dyserythropoiesis
Dysmyelopoiesis
Dysmegakaryopoiesis
Treatment
Blood transfusion
Chemotherapy
Hormone replacement therapy
Bone marrow transplant
This is to complete my log book as a part of my internship duty.
11/04/2020
A 47 year old female presented to OPD with complaints of
Difficulty in breathing since 10 days not aggravated or relieved with positional or diurnal variation
palpitations since 10 days which were short lasting
Bilateral pitting type of edema of lower extremities since 10 days
No h/o pain or warmth at the local sites of edema , no color change
No h/o facial puffiness or abdominal distention.
She is a known hypertensive pt since 20 years .
she is on medication tab . Telmisartan 20mg daily
H/o filariasis in rt lower limb since 15 years and is using medication DEC 100 mg for 2 weeks in a year.
On general EXAMINATION
Pt was c/c
Temperature:96.5 F
Bp:130/90mm Hg
Pulse:84 bpm
Spo2: 99%
CVS: S1 S2 heard
RESPIRATORY SYSTEM: b/l normal vesicular breath sounds
P/A: shape of the abdomen: obese
No free fluid ,scars ,sinuses
Hernial orifices normal
No tenderness
Liver is palpable 2-3 cms
Spleen is palpable- 4 cms
Bowel sounds present
CNS: HMF intact
Speech normal
Sensory system normal
Motor system normal
INVESTIGATIONS
Hemogram: On presentation she had hb-4.5 gm/dl .
After
1 st blood transfusion On12/05/20 hb:6.2 gm/dl
Total count:14,200 cells/cumm
Pcv:18.3 vol
Rbc:1.96 millions/cumm
Platelet: 1.01 lakhs/cumm
After 2 ndblood tranfusion
On 15/05/20 hb: 9gm/dl
Pcv:28.6 vol%
Mchc:31.3%
Rdw-cv 19.5%
Serum iron- 40ug/dl
Serum ferritin- 109ng/ml
Rft: urea- 10mg/dl
Sodium-139mEq/l
Potassium-4.1mEq/l
Chloride-104mEq/l
Lft:Total bilirubin-1.28mg/dl
Direct bilirubin-0.52mg/dl
SGOT-24IU/L
SGPT-12IU/L
Alkaline phosphate- 118IU/L
Total proteins - 5.7gm/dl
Albumin-3.7gm/dl
Blood smear picture :
RBC:hypochromic with anisopoikilocytosis comprising normocytes ,macrocytes ,tear drop cells,schistocytes, ,polychromasia and nucleated rbcs 2-3 / 100 wbc
WBC: normal count with hypersegmented neutrophils and mild shift to left
Platelets: adequate
No parasites
Impression: normocytic hypochromic anemia with hypersegmented neutrophils
-? Megaloblastic anemia
-? Hemolytic anemia
Osmotic fragility-lysis starts at 0.45%
Completes at 0.33%
Stool culture: no pus cells,no rbcs, no parasitic forms of ova / cyst seen
Stool for occult blood: positive
Serology is negative
Direct coombs test negative
Indirect coombs test POSITIVE
USG abdomen-splenomegaly
Fibroid uterus
Right hydrosalpinx
2d echo: mild dilated R.A/ R.V
PROCEDURE LEARNT: BONE MARROW ASPIRATION ( site- sternum) done on 13/05/20
First consent was taken from the patient for the procedure and the pt didn’t agree for video recording of the procedure. Then the patient was given a test dose of xylocaine. After half and hour at the level of 2 nd intercoastal space 10ml xylocaine was given then marrow was Aspirated.
Report: reactive marrow with erythroid hyperplasia
DIAGNOSIS:
?megaloblastic anemia
?hemolytic anemia
TREATMENT GIVEN:
Planned for 2 prbc blood transfusion
Inj. Vitcofol 2cc/im/od (D 3/5)
T.livogen 150mg/po/od for 1 month
T.MVT/po/od
Inj methylcobalamine 1 amp/im/od 500 mcg for 5 days (D1/5)
ADVICE AT DISCHARGE:
Inj. Hydroxocobalamin 1000 mcg for 3 days. Followed with weekly once for 1 month. Later on monthly once for 2 months
T. MVT po od for 1
Topic learnt today : myelodysplastic syndrome
(MDS)Myelodysplastic syndrome is a clonal hematopoietic stem cell disorder characterised by morphological dysplastic changes in one or more of major hematopoietic cell lines.
MDS can be presented with cytopenias - neutropenia, anemia and thrombocytopenia.
FAB classification was recommended early and as modified by WHO .
WHO uses percentage of blasts in bone marrow, ring sideroblasts and dysplastic changes to differentiate MDS subtypes.
1. Refractory anemia
2.refractory anemia with ringed sideroblasts
3. Refractory cytopenia with multilineage dysplasia
4. Refractory cytopenia with multilineage dysplasia and ringed sideroblasts
5.refractory anemia with excess blasts
6.myelodysplastic syndrome unclassified
7. MDS with isolated del (5q)
Some of the cytopenic causes are:
A.Chronic liver disease
B.drug induced cytopenia
C.excessive alcohol intake
D.b12/folate deficiency
E.autoimmune cytopenia
F. Anemia of chronic disorders
G . Parasitic infections
Stem cell disorders like IDUS,ICUS ,CCUS,CHIP
Intext source https://www.intechopen.com/books/recent-developments-in-myelodysplastic-syndromes/diagnosis-and-classification-of-myelodysplastic-syndrome
Clinical presentation : infection,bleeding/bruising ,gum bleeding,petechiae
Symptoms include general weakness, pallor,shirtness of breath
On physical examination enlarged spleen size.
Investigations : complete blood picture,serum ferritin, serum iron,stool culture,2d echo,USG abdomen, bone marrow aspiration.
Dysplastic changes include :
Dyserythropoiesis
Dysmyelopoiesis
Dysmegakaryopoiesis
Treatment
Blood transfusion
Chemotherapy
Hormone replacement therapy
Bone marrow transplant
Comments
Post a Comment