Case 1 splenomegaly

20 year old woman with Hypoproliferative anemia and hepatosplenomegaly

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Here is a case i have seen:(25 September 2020)

20 year old female studied upto 8th class and happily married 2years ago

Came with c/o yellowish discolouration of eyes since 1 year

SOB on exertion since 1year

Irregular menses since 1 year

Pt was apparently asymptomatic 1year ago

Then she developed yellowish discolouration of eyes 1year ago for which she used unknown medication(chetla mandu) and then she visited lb nagar kamineni and used medications, it subsided in 2months.At that time she was diagnosed with hypothyroid for which she used medication for 1month and stopped(no records available) 

H/o amenorrhea for 5months, 1year back then f/b regular menses for 6months, now again amenorrhoea since 4months,upt came out to be negative 3months ago

There is history weight loss - 

Almost 10 kgs from last year .it's unintentional weight loss 

She said she was 45-50 kgs before marriage .and she started noticing loosening of clothes since the onset of jaundice( since 1 year ) 

Present weight -34kgs

1 Month AGO:yellowish discolouration of eyes recurred 1month ago, associated with fever which lasted for 10days,loose stools, nausea and pain Abdomen,yellowish discolouration of urine, generalised weakness and sob on exertion + for which she visited local hsptl 1month ago and used medications till 2days back, but the symptoms did not subside. So she came to our hospital 

Outside usg (1month ago) hepatospeelnomegaly, mesenteric lymphadenopathy

Outside reports (1month ago) CUE alb ++, pus cells 12-14,hb 5.5,TLC 4,100.plt:2.76

TB 1.8,CRP Positive, widal mild positive

T3:3.34,T4:14.07,TSH:0.01 

All 4limbs tingling, numbness present since 1year on and off

No h/o pain Abdomen, loose stools, vomiting, 

no h/o any transfusions

Not a k/c/o HTN, DM,CAD

LMP 4months ago

O/E pt conscious coherent 

PR 120bpm,regular,normal volume

Bp 110/70

RR 20/min

Pallor +

Icterus+

Jvp:normal

Cvs:

Apical impulse in 5th ICS on mid clavicular line

Parasternal heave+

Heaving apex+

Epigastric pulsations+

S1 s2 +, no murmurs

GIT

Shape of Abdomen normal

Umbilicus inverted,central

No local rise of temp

Tenderness+ on deep palpation in right and left hypochindrium

Hepatomegaly+

Spleenomegaly+ 2cms below coastal line

Bowel sounds +

RS: BAE+, NVBS

CNS:HMF intact, no FND

Neck:solitary thyroid nodule+

Investigations on the day of admission:

Hb:6.7

TLC 4,400

Plt 2.07

Mcv 63.0

Mch 20.4

Pcv 20

PBS report microcytic hypochromic

Retic count 0.5%

ARC 0.2%

RPI 0.1%

Serum LDH 251

Serum iron 93

Direct Coombs negative

Indirect Coombs negative

Serum ferritin 6

LFT 

TB 2.6

DB 1.15

AST 73

ALT 40

ALP 557

TP 7.5

Alb 2.7

A/G 0.57

TFT:

T3-2.96

T4-17.65

TSH-0.07

Rft:

Urea14

creat0.4

Na 140,K 4.0,cl 105

Chest x ray done

Cue :alb+, sugar trace, pus cells 3-4

HbsAg, Hcv negative

Bgt :B positive

Ecg:

Day 2:

Hypoproliferative anemia under evaluation with hypoalbuminemia

no fresh complaints

O/E pt conscious coherent 

PR 120bpm,regular,normal volume

Bp 110/70

RR 20/min

Pallor +

Icterus+

JVP raised

Cvs:

Apical impulse in 5th ICS on mid clavicular line

Parasternal heave+

heaving apex+

Epigastric pulsations+

S1 s2 +, no murmurs

GIT

Shape of Abdomen normal

Umbilicus inverted,central

No local rise of temp

Tenderness+ on deep palpation in right and left hypochindrium

Hepatomegaly+

Spleenomegaly+

Bowel sounds +

2d echo:

Ultrasound abdomen:

Day 3:

No fresh complaints

o/e pt c/c/c

Afebrile

BP:110/70mmhg

PR:86/min

reports:

serum vit b12 levels done outside:201.6pg/ml(normal range 211 to 911)

rx:

1.oral fluids upto 1.5L/day

2.protein powder 2tsp in 100ml milk 1 PO/TID

3.tab.CARBIMAZOLE 5mg/PO/TID

?POEMS-

Polyneuropathy-tingling and numbness of all limbs

Organomegaly-Hepatosplenomegaly+

Endocrinopathy-Thyroid

Myeloma-gamma gap

Skin changes-Hyperpigmented legs

day 4:

No fresh complaints

o/e pt c/c/c

Afebrile

BP:110/60mmhg

PR:110/min

grbs 102mg/dl

Bone marrow biopsy done

reports:

PT 1.8

INR 1.3

APTT 35

BT 2min 30sec

CT 4min 30sec

MP negative

Hb 6.3

TLC 4,000

plt 1.8 lakhs/cc

rapid dengue:negative

Rx:

1.tab carbimazole 5mg/po/tid

2.oral fluids upto 1.5L/day

3.protein powder 2tsp in 100ml milk po/tid

4.inj methylcobalamin 1000micro grams/im/od

day 5:

No fresh complaints

O/E pt c/c

Pallor+, icterus+

PR 96/min

BP 120/70mmHg

Cvs:parasternal heave+

S1 s2 +, no murmurs

RS BAE+

P/A - soft, Non tender

Hepatospleenomegaly+

Bowel sounds+

Reports:

CBP 

HB - 6.8gm/dl

TLC - 6,200 cells/cumm

plt 2.06lakhs/cc

Rx:

1.Inj iron sucrose

2.Day 3 Inj methylcobalamin 

3.oral fluids upto 1.5L/day

4.protein powder 2tsp in 100ml milk po/tid

5.tab carbimazole 5mg/po/tid

Bone marrow report: