A 39M WITH PANCYTOPENIA

  Note - This is an a online e log book to discuss our patient's de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.

DOA - 20/11/2023

CHIEF COMPLAINTS:

The patient complaints of -

Generalized weakness since one week 

Easy fatigability since one week

Breathlessness on exertion since one week

HISTORY OF PRESENTING ILLNESS:

 Patient was apparently alright 1 week ago after which he developed generalized weakness which is insidious in onset, gradually progressive associated with easy fatigability. The patient also complains of breathlessness since 3 days which is insidious in onset and progressed from grade 1 to grade 3.

There is a h/o weight loss of around 10 to 12kg in the last two months.

No h/o orthopnea, PND. No history of fever, cough, cold, headache, nausea, vomiting, pain abdomen, burning micturition. 

PAST HISTORY:

Patient is not a known case of Hypertension, Diabetes mellitus, TB, Epilepsy, Bronchial asthma, Thyroid disorders

PERSONAL HISTORY:

Diet - Mixed

Appetite - Normal, patient is having difficulty in swallowing due to painful oral ulcers

Sleep - Adequate

Bowel and Bladder - Regular

Addiction - Consumes alcohol 90ml on alternate days since 15 years, has been chewing tobacco since last 10 years.

GENERAL EXAMINATION 

Patient is conscious, coherent and cooperative and well oriented to time, place and person

He is moderately built

There is presence of pallor and icterus

No cyanosis, clubbing, lymphadenopathy and pedal edema 

Vitals on admission - 

Temp - Afebrile 

BP - 90/60 mm hg 

PR - 120bpm 

RR- 18cpm 

SYSTEMIC EXAMINATION:

CVS:  S1, S2 heard , no murmurs 

CNS:  NAD 

RS:  B/L air entry + , trachea central , NVBS heard 

P/A : scaphoid, soft, non tender, bowel sounds heard

DVL referral was done I/v/o multiple ulcers noted over the hard palate, tip of tongue, dorsum of tongue, and ventral aspect of tongue along with patches of hyperpigmentation and diagnosed as Recurrent Aphthous Ulcers, advised to send ANA Profile, Mucopaine gel for local application and Multivitamin tablet.

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS: Pancytopenia under evaluation

TREATMENT GIVEN: 

3 units of PRBC transfusion

Inj Vitamin B12 1000mcg IV in 100ml NS

Inj Iron Sucrose 200mg in 100ml NS IV

Inj Tranexamic acid 1g TID

Inj Ceftriaxone 2g IV BD

Tab Levofloxacin 750mg OD

Cap Fluconazole 150mg OD

Tab Septran D/S BD

Tab MVT OD

Mucopaine gel for L/A TID

FURTHER PLAN OF ACTION - The patient is being shifted to a higher centre for bone marrow biopsy and Hematologist opinion as Hemoglobin is not improving adequately even on blood transfusions