Pancytopenia under evaluation
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I have 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 diagnosis and treatment plan.
1. Shortness of breath since 20 days
2. Leg pain on walking since 20 days
3. Pedal edema since morning
The patient was apparantly asymptomatic 20 days back. Then he developed shortness of breath which developed on walking for short distances (Grade 3) since 20 days.
There is a c/o leg pain on walking since 20 days. There is h/o trauma to left leg 3 months back.
C/o pedal edema since today. Involving left leg and foot. Pitting type.
No c/o cough, fever, vomitings, diarrhea.
H/o blood transfusion 10 days back at Suryapet. 4 units of blood given. H/o red colored urine after transfusion, fever for 2 days.
Not a k/c/o DM, HTN, TB, asthma, epilepsy.
The patient is married. Farmer by occupation.
Normal appatite
Takes mixed diet
Bowel and bladder habits regular
No known allergies
No addictions
On examination
Pt is c/c/c
Moderately built and nourished
Pallor +
Edema of left leg, pitting type +
No cyanosis, icterus, lymphadenopathy
Temp Afebrile
PR 90bpm
RR 17cpm
BP 110/70mmHg
SpO2 98% in room air
GRBS 159mg/dl
CVS S1 S2 +
RS BAE +
P/A soft, non tender, bowel sounds+
CNS no FAD
Provisional Diagnosis
Pancytopenia under evaluation
Investigations
Day 1
S
Patient has reduced weakness
O
Pallor +
Clubbing -
PR - 87 bpm
BP - 110/70mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vit B12 defeciency
P
1. Inj METHYLCOBALAMINE 1000mg IV OD
2. Inj IRON SUCROSE 1 amp in 100ml NS IV
3. Vitals monitoring
Day 2
S
Patient has reduced weakness
O
Pallor +
Clubbing -
PR - 87 bpm
BP - 110/70mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vit B12 defeciency
P
1. Inj METHYLCOBALAMINE 1000mg IV OD
2. Inj IRON SUCROSE 1 amp in 100ml NS IV
3. Vitals monitoring
Day 3
S
Patient has reduced weakness
O
Pallor +
Clubbing -
PR - 87 bpm
BP - 110/70mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vit B12 defeciency
P
1. Inj METHYLCOBALAMINE 1000mg IV OD
2. Inj IRON SUCROSE 1 amp in 100ml NS IV
3. Vitals monitoring
Day 4
Patient taken to Gen surgery opd for PR examination and to evaluate the presence of any hemorrhoids. No abnormality detected.
Also taken for gastroenterology referral to rule out any gi bleeding. Endoscopy was not performed in view of low platelet count. Bone marrow biopsy was adviced.
S
Patient has reduced weakness
O
Pallor +
Clubbing -
PR - 87 bpm
BP - 110/70mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vit B12 defeciency
P
1. Inj METHYLCOBALAMINE 1000mg IV 0D
2. Inj IRON SUCROSE 1 amp in 100ml NS IV
3. Vitals monitoring
Day 5
S
Patient has reduced weakness
O
Pallor +
Clubbing -
PR - 87 bpm
BP - 110/70mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vit B12 defeciency
P
1. Inj METHYLCOBALAMINE 1000mg IV 0D
2. Vitals monitoring
Day 6
S
Patient has reduced weakness
O
Pallor +
Clubbing -
PR - 87 bpm
BP - 110/70mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vit B12 defeciency
P.
1. Inj METHYLCOBALAMINE 1000mg IV 0D
2. Vitals monitoring
Day 7
S
Patient has reduced weakness
O
Pallor +
Clubbing -
PR - 78 bpm
BP - 110/80mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vit B12 defeciency
P
1. Inj METHYLCOBALAMINE 1000mg IV 0D
2. Vitals monitoring
Day 8
S
Patient c/o 2 fever spikes(101F)
O
Pallor +
Clubbing -
PR - 78 bpm
BP - 100/70mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vit B12 defeciency
P
1. Inj CEFTRIOXONE 1gm iv/bd
2. Tab VIT B12 po/od
Day 8
S
Fever spike in the morning
Not able to walk due to shivering in the legs during the fever spike
O
Pallor +
Clubbing -
PR - 66 bpm
BP - 100/60mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vitt B12 defeciency
P
1. Inj CEFTRIOXONE 1gm iv/bd
2. Tab VIT B12 po/od
Day 9
S
Fever spike in the morning
Not able to walk due to shivering in the legs during the fever spike
O
Pallor +
Clubbing -
PR - 87 bpm
BP - 110/70mmhg
Afebrile
Spo2 - at 99% on RA
RR - 18 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
A
Pancytopenia under evaluation
?Vitt B12 defeciency
P
1. Inj CEFTRIOXONE 1gm iv/bd
2. Tab VIT B12 po/od
Day 10
S
C/o fever spike in the morning
Not able to walk due to shivering in legs1
O
Pallor +
Clubbing -
PR - 85 bpm
BP - 100/60mmhg
Temp - 101.8 F
Spo2 - at 99% on RA
RR - 14 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
CUE
Color pale yellow
Appearance clear
Alb nil
Sugar nil
Bile salts and pigments nil
Pus cells 2-3
Epith cells 2-3
A
Pancytopenia under evaluation
?Vit B12 defeciency ?MDS
P
1. Inj CEFTRIAXONE 1gm iv/bd
2. Tab VIT B12 po/od
3. Monitor vitals 4 th hrly
Day 11
S
C/o 2 fever spikes
Generalised weakness
O
Pallor +
Clubbing -
PR - 82 bpm
BP - 100/60mmhg
Temp - 101.8 F
Spo2 - at 99% on RA
RR - 16 cpm
CVS - S1 S2 +
RS - BAE +
CNS - No FAD
Per Abdomen - Soft, non-tender, Bowel sounds +
P
1 unit SDP transfusion done yesterday. Serology for HIV, HbsAg and HCV all negative. Planned for bone marrow biopsy today.
1. Tab VIT B12 po/od
2. Tab PCM 650mg po/sos
3. Tepid sponging
4. Monitor vitals 4th hrly
Bone marrow aspiration and biopsy was done in the afternoon .
Patient had 2 episodes of vomiting ,and suddenly became breathless ,with profuse sweating ,cold peripheries ,feeble pulse ,BP -80/60 mmHg
Spo2 on room air -52 %
RR-38/ min
HR-110/ min
RS- Bae+ , clear
CVs -s1,S2 heard no murmurs .
ABG - severe metabolic acidosis -
PH-7.2
Hco3-5
Paco2- 9.2
Assessment- septic shock ? / Cardiogenic shock ?
Heart failure
Severe anemia
Plan - O2 inhalation
Ionotropic support- on noradrenaline .
Started on Piptaz
PRBC transfusion
( Informed to first on call sir on duty ) .
