A 50F (Hbs Ag positive) with pancytopenia

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     This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient- centered online learning portfolio and your valuable inputs.


 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, and investigations, and come up with a diagnosis and treatment plan.


A 50 year old female farmer by occupation presented to the OPD with 

CHIEF COMPLAINTS:

   - generalised weakness since 1 year

   - loss of appetite since 1 year

   - hematuria since 2 days 

   - dizziness since 6 months 

   - sob ( grade 2) since 6 months 

   - fever since 1 week

   - itching on right side of neck since 1 month


HISTORY OF PRESENTING ILLNESS 


Patient was apparently asymptomatic 2 years back then she developed swelling of left lower limb associated with pain and then swelling progressed to whole body due to which she got admitted to Osmania and was treated after which the swelling subsided. Patient was doing fine till 1 year of that event but then gradually developed generalised weakness, easy fatigability, loss of appetite,weight loss, sob ( grade 2-3) not associated with cough,cold or palpitations.

She has pruritus that also began with an inflammatory rash in her neck a month back that currently appears as a post inflammatory hyperpigmentation with a nodular appearance.

She has fever which is intermittent, low grade not associated with chills and rigors 

She also has Hematuria for which she went to local hospital where she found to have Anemia for which she was transfused 5 units of blood in a span of 20 days and was discharged. 
She was doing fine.

Since 6 months patient is experiencing similar complaints and went to hospital where she was found to have Anemia and got transfused 2 units of blood and came here as they were unsatisfied with the treatment there . She was admitted on Saturday July 08 

PAST HISTORY:


Not a known case of HTN, DM 2 , CVA, CAD, TB , EPILEPSY ETC 

She underwent hysterectomy surgery at the age 36 years after the third childbirth.

PERSONAL HISTORY: 

- mother of 3 children ( 2 sons and 1 daughter) 

- Diet - mixed 

- Appetite- decreased since 1 year

- Bowel and bladder- regular 

- Sleep-adequate

- Allergies - No
 

MENSTRUAL HISTORY:

- Menarche - 13 years age 

- Past - A Regular cycle 5/30 

- Present - hysterectomy done at the age of 36 yrs 

DAILY ROUTINE :

She wakes up at 5 o'clock and does her daily activities and then she prepares for breakfast and has breakfast at 7 o'clock and then goes for work and at 12 o'clock she has her lunch near the field and in the evening she gets home bt 7 o'clock and prepares for dinner, eats it and then goes to bed at 9-10 pm.

After symptoms:

She is not going to any work since 1 and half year she stays at home and takes rest.

GENERAL EXAMINATION:

- Patient is concious , coherent, cooperative and l well oriented to time, place and person.
- Poorly built and poorly nourished 
- Patient is examined in a well lit room after taking consent with adequate exposure.










Pallor -present 

Icterus - positive 

Cyanosis - negative

Kolinychia - negative 

Clubbing - negative 

Generalised lympadenopathy - negative 

Edema - negative


VITALS:

BP- 90/60mmhg 

PR- 84bpm 

RR- 16 cpm

SYSTEMIC EXAMINATION 

Rs - BAE +ve , NVBS

CVS - S1 S2 heard , no murmurs 

CNS - NFND

P/A - spleenomegaly 

         Size- 17.5 * 15 cms

         Surface - smooth 

         Consistency - firm

         Borders- rounded borders







Spo2 - 98% at RA
Temp- afebrile 


PROVISIONAL DIAGNOSIS


- PANCYTOPENIA UNDER EVALUATION 

- ? AKI ( pre renal) 

- Denovo HBSAG positive 


INVESTIGATIONS























TREATMENT :

- Tab.dolo 650mg po/sos
- Sup.aristozyme 10ml po/tid 
- Tab.orofer XT po/OD 
- Temp monitoring 4th hrly 
- Vitals monitoring 4th hrly  
Ji


9/07/23


S: Stools passed

No fever spikes 

Tingling and numbness present



O:
   Pt is conscious,coherent and cooperative
   No pallor,icterus,cyanosis,clubbing,
lymphadenopathy,edema


• Bp - 100/60mmHg
• Pr - 84bpm
• Temperature - Afebrile
• Rr - 16 cpm  


CNS: NFND
CVS-S1,S2 heard ,no murmurs
RS- BAE present, NVBS Heard, no added sounds 
P/A- spleenomegaly 


A:
Pancytopenia under evaluation. ?AKI ( Pre-renal)
DENOVO HBsAg +ve 

P:
- T.Dolo 650mg PO/SOS
- Syp. ARISTOZYME 10ml PO/TID
-inj.vitcofol 1ml IM/OD
- Temperature monitoring 4th hourly
- Vitals monitoring 4th hourly



10/07/2023

Ward : WARD
Unit : 6
DOA : 8/7/23

Dr Nithin (pgy1)
Dr Nishitha (pgy2)
Dr Zain (SR)


S:
Stools passed
No fever spikes
No fresh complains 

O:
Pt is conscious,coherent and cooperative
No pallor,icterus,cyanosis,clubbing,
lymphadenopathy,edema

Bp - 100/60mmHg
Pr - 86bpm
Temperature - Afebrile
Rr - 16 cpm  

CNS : NFND
CVS-S1,S2 heard ,no murmurs
RS- BAE present, NVBS Heard, no added sounds 
P/A- spleenomegaly 


A:
Pancytopenia under evaluation
?AKI ( Pre-renal)
DENOVO HBsAg +ve 

P:
- T.Dolo 650mg PO/SOS
- Syp. ARISTOZYME 10ml PO/TID
- Temperature monitoring 4th hourly
- Vitals monitoring 4th hourly



12/07/2023

Ward : WARD
Unit : 6
DOA : 8/7/23

Dr Govardhini(pgy1)
Dr Nishitha (pgy2)
Dr Zain (SR)


S:
Complaining of giddiness
Stools not passed
No fever spikes

O:
Pt is conscious,coherent and cooperative
No pallor,icterus,cyanosis,clubbing,
lymphadenopathy,edema

Bp -100/70mmHg(while sleeping) 
      -100/70mmhg( while standing )
Pr - 69bpm
Temperature - Afebrile
Rr - 17cpm  

CNS: NFND
CVS - S1,S2 heard ,no murmurs
RS - BAE present, 
        NVBS Heard, 
        no added sounds 
P/A- soft and non tender                      spleenomegaly 


A:
Pancytopenia under evaluation
?AKI ( Pre-renal)
DENOVO HBsAg +ve 
Autoimmune haemolytic anemia 

P:
- Syp. ARISTOZYME 10ml PO/TID
-inj.vitcofol 1ml IM/OD
-T.pregabalin 75mg PO/HS
-T.Levocetrizine 5mg PO/HS
- Temperature monitoring 4th hourly
- Vitals monitoring 4th hourly

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