A 40 yr old female with severe anaemia

 A 40 yr old unmarried female c/o

Generalized weakness since 1yr
Decreased appetite since 1 yr
Bleeding PV since 4 days
She is a second born child of her parents ( 3rd degree consanguinous marriage)
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.
Not a k/c/C/o DM, HTN, thyroid, epilepsy, asthma.
Appetite decreased since 2ys only 1 meal /day.
Pica +

Milestones - delayed and difficulty in learning. 

General examination
Patient is c/c/c thin built and malnourished
Pallor ++, 






no icterus, cyanosis, clubbing, edema
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

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

Gait-1, 2, 3
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

https://youtube.com/shorts/sujnx53d3v8?feature=share3
https://youtube.com/shorts/WDWWCVtzCtc?feature=share4
https://youtube.com/shorts/X3qKLSEa-qY?feature=share5
https://youtube.com/shorts/ppdKgiySvmc?feature=share6
https://youtube.com/shorts/1uTq4TOJJsc?feature=share7
https://youtube.com/shorts/6GIE9gapsM0?feature=share8
https://youtube.com/shorts/jDYjbKtSgh8?feature=share9
. 
RS - BAE +
P/A - 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
ECG ON 08/02/2022


Chest X ray


Usg
-Abdomen
-neck

2D Echo

https://youtube.com/shorts/CB7ekL7fFE4?feature=share1
LFt
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.                                           
RBC - microcytic hypochromic with target cells, fragmented forms, pencil forms and severe anisopoikilocytosis
WBC - count increased, neutrophils show toxic granules
Impression - Microcytic hypochromic anaemia with neutrophilic leucocytosis and moderate thrombocytopenia. 


Reticulocyte count - 1.4%
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
                                                        
                                                     

Diagnosis - Bicytopenia under evaluation
Rx
 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

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