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I am Nomika Alli (Roll no 179) of 3rd Sem MBBS.
A 48 yr old female R/O Nalgonda came to OPD with chief complaints of fever associated with chills and rigor since 3 days. She is having a history of Splenomegaly from the past 2-3 yrs who presented to the hospital after having fever with chills at home.
No H/o body pains, sore throat
No H/O Rash
No H/O pain abdomen, pedal edema, vomitings, loose stools
History of present illness:
The patient is a 48 year old woman, daily wage labourer by occupation. She was married at the age of 16 years and had her first child (male) at the age of 18 years, second child (male) at the age of 23 years and her third child ( male ) at the age of 28 years. All the three times she had normal deliveries and had no complications during her pregnancies. Her third child died at the age of 3 days due to unknown illness. Her two elder sons are leading completely normal lives until now. The patient was completely asymptomatic until the birth of her third child.
In few months following the death of her son, when she was 28 yrs old, she developed abdominal pain and mass per abdomen for which she went to a hospital in Guntur for which she was given some medication ( unknown ) which she used for about 2-3 years. Her complaints did not subside with that and so she went back to the same hospital and was referred to KIMS, Nkp. She was given some medication (unknown) in KIMS, which she used for about 2-3 months. With these her pain subsided but mass did not. Patient was comfortable as her pain subsided and so she stopped the medication. All throughout her illness the patient was able to carry on with her daily activities and was going to work everyday.
Her daily routine was waking up at 5 am in the morning , drinking tea at 7 am , having her breakfast as rice with curry at 9 am and leaving to work. She is going to have her lunch as rice with curry at 1 pm and continue with her work. She used to return home by 5 pm and have her dinner as roti/ rice with curry at 7 pm. She used to have regular and normal bowel and bladder movements.
In 2018, she came to KIMS, Nkp , with c/o abdominal pain in the hypochondrium , dull aching type, non radiating.
After investigations:
- Direct Coombs +ve
- Leukopenia +
- Thrombocytopenia +
- ANA titre 14.2 IU/ml
- Anti Sm +
- APLA ( Ig G ans Ig M ) +
- Rash on back was present
Patient was diagnosed with portal vein thrombosis with splenomegaly and was on treatment since then.
She again came for a regular checkup in 2019 and was continued on the same medication.
USG report from 2019:
She was admitted in KIMS, Nkp on 20/2/2020 with c/o abdominal pain and generalised body pains.
Her hemogram report from feb 2020:
Hb- 9.5
TLC- 16,000 (high)
PLC- 40,000 (thrombocytopenia)
She was advised to use the following medication:
- T. PROPRONOLOL 20MG H/S
- T. HCQ 200MG H/S
- T.PREDNISOLONE 10MG /OD
- T.FOLATE 5MG /OD
- T.PAN 40MG /OD
- T.SHELCAL 500MG /OD
The patient has been using these till date.
The patient says she feels comfortable when taking these medication and her appetite has improved.
H/O intermittent stoppage of medication.
She is able to carry out her daily activities on her own but is not able to go to work everyday since the last 3 years due to her illness. She goes to work when she feels well ( about 15-20 days in a month) .She was also advised not to lift heavy weights and not to perform strenuous activities.
Present :
Complaints of fever with chills and rigors since 29/10/21 (Friday) which subsided by the time of presentation on 1/11/21 ( Monday ). No fever spikes since then . She stopped using her medication since the day of onset of fever.
She has H/O Esophageal varices ( Grade III ) 3 and 1/2 years ago for which banding was done .
Not a k/c/o HTN/DM/TB/Asthma
No drug allergies
No significant family history.
PERSONAL HISTORY:
Takes mixed diet.
Normal appetite
Regular bowel and bladder movements
No known allergies.
No addictions.
VITALS
Temperature: Afebrile
PR: 100BPM
RR:18CPM
BP:100/80MMHG
SPO2:100%
GRBS:. 86 MG/DL.
O/E:
Pt is c/c/c
PALLOR: +
No icterus, cyanosis, clubbing, lymphadenopathy, edema.
No malnutrition.
No dehydration.
CVS: S1S2+ No murmurs
RS: BAE+ No crepts
PER ABDOMEN:
SOFT
NON TENDER
MASSIVE SPLENOMEGALY+
SPLEEN IS PALPABLE
CNS: NAD
ECG :
CHEST X-RAY
PROVISIONAL DIAGNOSIS:
INFECTION SECONDARY TO DISCONTINUATION OF MEDICATION. WITH PANCYTOPENIA
K/C/O PORTAL VEIN THROMBOSIS.
PLAN OF CARE:
- T. PROPRONOLOL 20MG H/S
- T. HCQ 200MG H/S
- T.PREDNISOLONE 10MG /OD
- T.FOLATE 5MG /OD
- T.PAN 40MG /OD
- T.SHELCAL 500MG /OD
- T. AUGMENTIN 625MG /BD.
DAY 2
S: NO FEVER SPIKES
NO FRESH COMPLAINTS
O:
O/E
Pt c/c/c
Temp-97.6 F
BP- 100/80 mmhg
PR- 83 bpm
Pallor +
CVS-S1 S2 +. No murmurs
RS- BAE +
P/A- soft, non tender
Spleenomegaly ++
CNS- NAD
Hemogram:
Hb. 8.9
TLC- 700
PLC- 60,000
Blood Group - B+ve
ESR- 25 mm/hr
A:
INFECTION SECONDARY TO DISCONTINUATION OF MEDICATION.WITH PANCYTOPENIA
K/C/O PORTAL VEIN THROMBOSIS.
P:
- T. PROPRONOLOL 20MG H/S
- T. HCQ 200MG H/S
- T.PREDNISOLONE 5MG /OD
- T.PAN 40MG /OD
- T.SHELCAL 500MG /OD
- T. AUGMENTIN 625MG /BD
- T. CIPROFLOXACIN 500 MG/ BD
OPTHALMOLOGY CONSULT:
Day 3
S: NO FEVER SPIKES
NO FRESH COMPLAINTS
O:
O/E
Pt c/c/c
Temp-97.6 F
BP- 110/80 mmhg
PR- 63 bpm
Pallor +
CVS-S1 S2 +. No murmurs
RS- BAE + No crepts
P/A- soft, non tender
Spleenomegaly +
CNS- NAD
Hemogram:
Hb. 9.3
TLC- 960
N-50
L/M/E- 40/9/1
PLC- 45,000
Blood Group- B+ve
A:
INFECTION SECONDARY TO DISCONTINUATION OF MEDICATION.
WITH PANCYTOPENIA
K/C/O PORTAL VEIN THROMBOSIS.
P:
- T. PROPRONOLOL 20MG H/S
- T. HCQ 200MG H/S
- T.PREDNISOLONE 10MG /OD
- T.PAN 40MG /OD
- T.SHELCAL 500MG /OD
- T. AUGMENTIN 625MG /BD
- T. CIPROFLOXACIN 500 MG/ BD
Day 4
S: NO FEVER SPIKES
NO FRESH COMPLAINTS
O:
O/E
Pt c/c/c
Temp-97.8 F
BP- 110/60 mmhg
PR- 65 bpm
RR- 16 cpm
Pallor +
CVS-S1 S2 +. No murmurs
RS- BAE + No crepts
P/A- soft, non tender, BS+
GRBS- 99% at RA
IP/OP -1450ml/1150 ml
Spleenomegaly+
CNS- NAD
Hemogram:
Hb. 9.4
TLC- 1100
N-50
L-40
PLC- 42,000
Blood Group- B+ve
A:
INFECTION SECONDARY TO DISCONTINUATION OF MEDICATION.
WITH PANCYTOPENIA
K/C/O PORTAL VEIN THROMBOSIS.
P:
- T. PROPRONOLOL 20MG H/S
- T. HCQ 200MG H/S
- T.PREDNISOLONE 5MG /OD
- T.PAN 40MG /OD
- T.SHELCAL 500MG /OD
- T. AUGMENTIN 625MG /BD
- T. CIPROFLOXACIN 500 MG/ BD
- T. MVT PO/OD
Note:
This elog was done under guidance of Varaprasad sir (2016).
Source: https://trishaalareddy121.blogspot.com/2021/11/43-year-old-female-with-pancytopenia.html
Any reviews ,comments, inputs, advices about the content presented is absolutely welcome !!!
Thanks & Regards,
Nomika Alli
3rd SEM
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