CASE OF A DIMORPHIC ANEMIA .
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45 year old female who is a housewife survived with 3 kids came to casualty with
C/O Vomitings ( food particle as content , non bilious , non projectile ) Since yesterday there were 10 episodes
- C/O giddiness since 1 day
HOPI:-
- Patient was apparently assymptomatic 1 month back then she had decreased appetite since 1 month
- C/O weight loss since 1 month
- C/O Shortness of breath ( grade 2 - grade 3 ) according to NYHA Classification, not associated with Orthopnea / PND since 15 days
- H/O Heavy bleeding since 10 days (3-4 pads/day)
- C/O B/L Pedal edema since 10 days
Past history :-
- H/O similar complaints in the past diagnosed with megaloblastic anemia in the year 2017
- H/O Hemorrhoids in the year 2014
- H/O Recurrent Blood Transfusion since 2014
- Not a k/c/o DM/ HM/ Asthma / Epilepsy
PERSONAL HISTORY:
Married female
Appetite - Decreased
Diet :- mixed
Bowels:- regular
Micturition:- normal
- No addictions
Family history:- Not significant
General examination:-
Patient is conscious , coherent , cooperative
- oriented to time , place , person
- Pallor +
- No icterus , clubbing , cyanosis , odema, lymphadenopathy
VITALS:-
Temp:- 98.5
PR:- 112/min
RR:- 18/min
BP:- 90/60mmhg
SPO2:- 99%
GRBS:- 105mg %
Systemic examination:-
CVS:- S1S2 + PANSYSTOLIC Murmurs + Raised JVP
Link for raised JVP
https://youtube.com/shorts/bmmtcdqCMlQ?feature=share
RS:- BAE + , No crepts
P/A:- Splenomegaly +
CNS:- No abnormality detected.
Provisional diagnosis :-
ANEMIA UNDER EVALUATION ? MEGALOBLASTIC ANEMIA ( VitB12 deficiency ).
Investigations:-
Serum LDH:- 4294 IU/L
Serum IRON:- 30 mg/dl
ESR :- 30 mm/1st hour
Serum electrolytes :-
Na:- 131 meq/L
K:- 3.9 meq/L
Cl:- 99 meq/L
Blood urea :- 18mg/dl
Creatinine :- 0.6
CRP:- Negative
USG Abdomen and pelvis :-
mild splenomegaly
2D ECHO:-
EF:- 60%
Rvsp:- 45mmhg
IVC Size ( 0.9cms ) collapsing
-Moderate to severe MR, Mild TR + with PAH? , Trivial AR +
NO RWMA , NO AS/MS , Sclerotic AV
- Good Lv systolic function
- Diastolic Dysfunction ++ , No PE
LIVER FUNCTION TESTS:-
Total Bilirubin :- 1.87 mg/dl
Direct Bilirubin :- 0.42 mg/dl
AST:- 106 IU /L
ALT:- 18 IU/L
ALP:- 102 IU / L
TP:- 4.9 gm/dl
Albumin:- 2.9 gm/dl
A/G :- 1.49
Direct Coombs :- Negative
Indirect Coombs :- Negative
Hemogram:-
Hb:- 4.0gm/dl
TLC:- 3,800
N/L/E/M:- 38/56/01/05
PCV:- 11.4
MCV:- 95.0
MCH:- 33.3
MCHC:- 35.1
RBC COUNT :- 1.20
PLT COUNT - 60,000
SMEAR :-
RBC:- Anisopoikilocytosis with hypochromasia , microcytes , macrocytes , ovalocytes , teardrop cells , pencil cell forms .
WBC:- mild leukopenia , hypersegmented neutrophils seen
PLATELETS :- reduced on smear
IMPRESSION:- Pancytopenia
Obg referral done on 17/3/22
MANAGEMENT :-
1) Inj METHYLCOBALAMINE 1500mcg in 50ml NS/ IV/ OD
2) Inj TRANEXAMIC ACID 1 Amp IV/BD
3) Tab ZOFER 4mg IV/ SOS
4). Inj NEOMOL 100ml ( if temp greater than 101.1 )
5) Inj PAN 40mg IV/ OD
6) Monitor Vitals Hrly
SOAP NOTES
Day 2
ICU BED 2
S:-
- C/O Burning Micturition
- No vomiting episodes
- No giddiness
- SOB reduced
O:-
Patient is conscious , coherent , cooperative
- oriented to time , place , person
Temp:- 97.3
PR:- 104
BP:- 90/60
RR:- 18 cpm
SPO2 :- 98%
GRBS:- 104mg/dl
CVS:- S1S2 + , No murmurs
RS:- NVBS + , No crepts
P/A :- Splenomegaly +
A:- Anemia secondary to ? nutritional deficiency ( B12)
P:-
1) Inj METHYLCOBALAMINE 1500mg in 50ml NS/IV / OD
2) Inj PAN 40mg IV/OD
3) Inj ZOFER4mg IV/SOS
4) Inj NEOMOL 100ml ( if temp > 1
Plan for gynec review
SOAP NOTES
Day 3
ICU BED
- C/O Burning Micturitio
- No vomiting episod
- No giddines
- SOB reduce
Patient is conscious , coherent , cooperativ
- oriented to time , place , perso
Temp:- 97.
PR:- 94 low volume regula
BP:- 90/
RR:- 20cp
SPO2 :- 9
GRBS:- 120mg/
CVS:- S1S2 + , No murmu
RS:- NVBS + , No crept
P/A :- Splenomegaly
- Thrombophelitis
A:- Anemia under evaluation
? Megaloblastic anemia
D3 1) Inj METHYLCOBALAMINE 1500mg in 50ml NS/IV /
2) Inj PAN 40mg IV/
3) Inj ZOFER4mg IV/S
4) Inj NEOMOL 100ml ( if temp > 101.1
5) Monitor Vitals Hrly.
Hemogram on 19/2/22:-
Hb:- 5.7
TLC:- 4,640
N/L/E/M :- 53/43/00/04
PCV:- 15.3
MCV:- 90.8
MCH:- 33.8
MCHC:- 37.2
RBC:- 1.68
PLT COUNT :- 35,000
SOAP NOTES
Day 4
ICU BED 2
S:-
- C/O Burning Micturition
- No vomiting episodes
- No giddiness
- SOB reduced
O:-
Patient is conscious , coherent , cooperative
- oriented to time , place , person
Temp:- 98.1
PR:- 88bpm Regular
BP:- 100/70mm Hg
RR:- 20cpm
SPO2 :- 98%
GRBS:- 113mg/dl
CVS:- S1S2 + , No murmurs
RS:- NVBS + , No crepts
P/A :- Splenomegaly +
A:- Anemia under evaluation
? Megaloblastic anemia
P:-
D4 1) Inj METHYLCOBALAMINE 1500mg in 50ml NS/IV / OD
2) Inj PAN 40mg IV/OD
3) IHemogram on 20/3/22:-
Hb:- 6.2
TLC :- 4,400
N/L/E/M:- 59/34/02/05
PCV:- 17.8
MCV:- 92.3
MCH:- 32.3
MCHC:- 34.9
RBC:- 1.93
PLT Count :- 50,000
SOAP NOTES
Day 5
AMC BED 1
S:-
- C/O Burning Micturition
- No vomiting episodes
- No giddiness
- SOB reduced
O:-
Patient is conscious , coherent , cooperative
- oriented to time , place , person
Temp:- 98.1
PR:- 100bpm Regular
BP:- 90/60 mm Hg
RR:- 20cpm
SPO2 :- 98%
GRBS:- 110mg/dl
CVS:- S1S2 + , No murmurs
RS:- NVBS + , No crepts
P/A :- Soft , Tenderness in left Hypochondrium ,
Splenomegaly +
A:- Anemia under evaluation
? Megaloblastic anemia with
Denovo Hypothyroidism
18/3/22
Hemogram :-
Hb- 4.7
TC:- 4,900
N- 54
L- 42
PCV- 12.6
MCV:- 91.5
MCH- 33.8
MCHC- 36.9
RBC -1.38
PLT - 30,000
SMEAR - Macrocytic Normochromic macroovalocytes , microcytes target cells , polychromatophil NRBC
Thyroid tests :-
T3:- 0.59
T4:- 5.80
TSH- 8.06
Sickling test:- Negative
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