DIMORPHIC ANEMIA WITH LEUKOPENIA
DIMORPHIC ANEMIA WITH LEUKOPENIA
24 yr old male patient studying 10 class
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Name : B.Krishna (9th semester)
Roll number : 68
24YEAR OLD MALE PATIENT CAME TO THE CASUALITY ON 20 /10/21
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.
Presenting complaints are :
1)c/o fever since 10days
2)c/o vomitings since 10days
3) c/o dry cough since 7 days
4)c/o constipation since 2 days
HOPI
The patient was apparently asymptomatic 10 days back then he developed fever which is insidious in onset ,progressive and high grade. Relieved on medication.There were no diurnal variation Cough - dry cough since 7 days, relieved on medication. Constipation since 2 days.Vomitings since 10 days which is non projectile and bilious with content of food particles.
NEGATIVE HISTORY
No history of any abdominal pain , hemopytisis or blood in stool.
PAST HISTORY
not a known case of hypertension,asthma, diabetes,tuberculosis,seizures, thyroid diseases.
Personal history :
Appetite: normal
Diet : vegetarian
Bowel; irregular, difficulty in passing stools since 2 days
Bladder: regular
Sleep; adequate
No addictions
Family history :
Not significant
General Examination :
Patient is conscious coherent and cooperative well oriented to time place and person.
pallor present
No cyanosis,
No clubbing,
No lymphadenopathy,
No oedema
Vitals :
Temp-febrile
PR-130 bpm
RR-17 cpm
BP-130/70 mmhg
Systemic Examination:
PER ABDOMEN EXAMINATION
Inspection :
Palpation :
mild hepatimegaly and splenomegalyis present.no tenderness,or local rise of temperature.
Palpatation
Liver dullness is heard.No fluid thrills , shifting dullness
Auscultation :Bowel sounds are heard
Provisional diagnosis; viral pyrexia with thrombocytopenia with anemia
CLINICAL IMAGES :
On 20/10/21
Ldh-554
LFT;
Total bilirubin-2.09
Direct bilirubin-0.41
AST- 30
ALT-10
ALP-112
Total proteins-6.1
Albumin-3.4
A/G ratio- 1.30
Serum creatinine- 1.1
Sodium- 138
Potassium- 3.9
Chloride-101
Hemogram;
Hb-5.7
TLC-4,400
Pcv-17.4
Rbc-1.9million/cu mm
Platelet count-1.20 lakh/cu mm
Smear ;microcytic hypochromic anemia with thrombocytopenia
On 21/10/21
Serum iron-100mcg/dl
RBS-89mg/dl
Smear: Anisopoikilocytosis with hypochromia with microcytes,few fenici forms,macrocytes and macro ovalocytes
Impression: Dimorphic anemia with leukopenia
Treatment;
1) inj.Neomol 1gm iv sod
( If temperature > 101°f)
2) Tab Dolo650mg po sos
3) Tab orofer-XT po BD
4)syp.Ascoril 10ml po BD
10-x-10ml
5) syrup cremaffin -10ml po-HD
X-X-10ml
6) inform sos
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