48 year old female with pancytopenia
48yr old female , daily wage labourer, has two male children, came to casualty with cheif complaints of
Fever associated with chills and rigor a since 3days.
No H/o body pains, sore throat
No H/O Rash
No H/O pain abdomen, pedal edema, vomitings, loose stools
HOPI:
The patient is a 48 year old woman, agricultural 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 elders 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 third 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 (agricultural labourer) everyday.
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
As per SLICC criteria ( any 4) patient was diagnosed with SLE 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
PLC-40,000
She was advised to use the following medication:
Tab propronolol 20 mg h/s
Tab HCQ 200 mg h/a
Tab Prednisolone 5 mg OD
Tab Folate 5 mg OD
Tab Pantop 40 mg OD
Tab Shelcal 500 mg 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.
H/O Esophageal varices ( Grade III )
31/2 years ago for which banding was done
Not a k/c/o HTM/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.
ICVS: S1S2+ No murmurs
RS: BAE+ No crepts
PER ABDOMEN:
SOFT
NON TENDER
MASSIVE SPLENOMEGALY+
SPLEEN IS PALPABLE
CNS: NAD
INVESTIGATIONS:
HEMOGRAM:
HB: 9.1
TLC:1000
N:50%
L:50%
PLT: 50,000
RBS: 149 MG/DL
BLOOD UREA: 17MG/DL
LFT:.
TB:1.65
DB:0.60
SGOT:27
SGPT:10
ALP:92
TP:6.4
ALB:3.6
A/G:1.30
SERUM CREATININE: 0.8
SERUM ELECTROLYTES
Na:140.
K:3.5
Cl:2.5
URIC ACID: 2.5
ECG
CHEST X-RAY
PROVISIONAL DIAGNOSIS:
SLE FLARE-UP/INFECTION SECONDARY TO DISCONTINUATION OF MEDICATION.
WITH PANCYTOPENIA
K/C/O SLE WITH PORTAL VEIN THROMBOSIS.
PLAN OF CARE:
1 . T. PROPRONOLOL 20MG H/S
2. T. HCQ 200MG H/S
3. T.PREDNISOLONE 10MG /OD
4. T.FOLATE 5MG /OD
5. T.PAN 40MG /OD
6. T.SHELCAL 500MG /OD
7.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
A:
SLE FLARE-UP/INFECTION SECONDARY TO DISCONTINUATION OF MEDICATION.
WITH PANCYTOPENIA
K/C/O SLE WITH 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
USG ABDOMEN:
OPHTHALMOLOGY CONSULT
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