MEDICINE CASE DISCUSSION
A 40 yr old female with severe anaemia
Feb 11,2022
P.Manasa
9th semester
Roll no:- 102
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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.
CASE
A 40 yr old unmarried female c/o
CHIEF COMPLAINTS:
*Generalized weakness since 1yr
*Decreased appetite since 1 yr
*Bleeding PV since 4 days
HISTORY OF PRESENT ILLNESS:
She is a second born child of her parents (3rd degree consanguinous marriage)
Menstrual history:-
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 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.
PAST HISTORY:
Not a k/c/C/o DM, HTN, thyroid, epilepsy, asthma.
PERSONAL HISTORY:
*Pica +
*Milestones - delayed and difficulty in learning.
FAMILY HISTORY:
Insignificant
GENERAL EXAMINATION:
The patient was examined in a well-lit room after informed consent was taken.
Patient is c/c/c thin built and malnourished
Pallor ++,
no icterus, cyanosis, clubbing, edema
VITALS:-
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
SYSTEMIC EXAMINATION:
CVS
Inspection -
JVP raised
Apical impulse diffuse in 5th and 6th IC space
Palpation - thrills and para sternal haeve +
apex beat in mud 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
. RESPIRATORY SYSTEM
BAE +
Normal vesicular breath sounds heard
PER ABDOMEN
- 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
09/02/2022.
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.
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
TREATMENT
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
