A 21 year old female with anemia
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I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history , clinical finding , investigation and come up with diagnosis and treatment plan
CASE:
21 year old female came to gm op with chief complaints of easy fatiguability ,light headedness since 7 years
C/o sob since 7 years ( sometimes )
No c/o Fever, burning micturation,vomitings, loose stools
No c/o involuntary movements or tingling sensation or numbness .
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 20 years back then she developed fever , edema over the fronto parietal region and irritability she was admitted in the hospital treated ( her hospital stay was around 10 days and she was discharged )
At the age of 3 years she had an episode of giddiness and was unconscious, she was again admitted in the hospital and then they were told that she had low levels of hemoglobin and she underwent blood transfusion.
At 15 years of age she was taken to the hospital for weakness, giddiness , she was admitted in the hospital and had second episode ofblood transfusion, her hemoglobin level improved to 9 after blood transfusion.
Few months after blood transfusion she started feeling weak and again went to the hospital , then her blood hemoglobin went down to 4 .
Since 3 to 4 months she complains of joint pains
Since 20 days she has allergy over her palms ,she has itching all over her hands relieved after taking medication at local hospital.
Since 20 days anasarca ( intermittently )
Resolved by its own . Last episode 2 days back
From 10 years of age she started noticing hyperpigmentation patches on her body which was slowly progressive to current stage .(neurofibromatosis )
Past history: history of trauma to head at the age of 10 while playing under a tree .
Daily routine:
Childhood
During the days she felt alright:
She wakes up at 6 Am ,does all the house hold work , she helps her mother and has breakfast at 8 Am and goes to school by walk (around 2 km ) , and comes back in the evening around 5 (by walk ) and plays with her friends and has dinner at 8 pm and goes to sleep by 10 pm
During summer holidays she went to work in the field ( cotton farms and chilli farms )
From morning 10 Am to evening 5 pm .
She studied till intermediate and didn’t go any further to college because of illness.
After progression of her illness she didn’t go to work in the fields , she helped her mother in all the household activities.o
PAST History:
She is not a known case of DM, HTN, CVA, CAD, asthma, epilepsy.
FAMILY HISTORY:
Her sister has low value of hemoglobin (hb -6 gm/dl),but her sister doesn’t complain of any weakness.
Her mother has neurofibromatosis
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative.
Mooderately built and moderately nourished.
Pallor - present
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
No lymphadenopathy
Pedal edema-
Vitals :
Temperature - 98.2 F
Blood Pressure - 120/80mm hg
Pulse Rate - 82 bpm
Respiratory Rate - 16 cpm
SYSTEMIC EXAMINATION:
PER ABDOMINAL EXAMINATION:
INSPECTION-
Shape of abdomen : flat
Umbilicus : inverted
All quadrants of abdomen move with respiration
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites
No tenderness, local rise of temperature
Normal expansion of chest on both sides in all areas
Position of trachea: Central
Vocal fremitus: resonant note felt
PERCUSSION:
Resonant note heard over all areas
AUSCULTATION:
BAE positive
Vocal resonance: resonant in all areas
CNS :No focal neurological deficit
Patients mother
Provisional diagnosis:
Iron deficiency Anemia secondary to ? Blood loss ? Thalassemia minor k/c/o neurofibromatosis.
INVESTIGATIONS:
ECG
2d echo :
Trivial TR/AR/MR
No RWMA , NO AS/MS
Good LV systolic function, No diastolic dysfunction.
4/7/2023 investigations
Hemogram :
Hb-6.4
TlC- 11200
N /L/E/M -35,19,41,5
PCV-25.9
MCV- 56.9
MCH-14.1
MCHC-24.7
RDW-27.2
Smear:
MICROCYTIC HYPOCHROMIC FEW PENCIL FORMS AND TARGET CELLS SEEN
WBC :normal limit with eosinophilia
Plt - adequate
BGT :A positive
RETICULOCYTE : 1.5
BLOOD UREA -18
SERUM CREATININE:0.6
Na - 140
K -4.7
Cl-102
LFT :
Total bilirubin: 0.49
Direct bilirubin:0.15
AST-14
ALT-10
ALP-128
TP:6.7
ALBUMIN: 4.35
A/g :1.85
Serology: negative.
Ultrasound 5/7/2023
Mild splenomegaly .
Serum ferritin :73.5 ng/ml
Stool for occult blood - negative
8-7-2023
HBA -98.4%
HBA2-1.6%
TIBC-394 ug/dl
TRANSFERRIN SATURATION -8%
UIBC-363.9ug/dl
IRON -30ug/dl
Hemogram 10. -7-23
Hb-6.8
TLC -7500
N -30 ,L-25 ,E-40 ,M-5 , B-0
PCV-27.3
MCV-59
MCHC -24.9
MCH-14.7
