CPS

A 45 years old woman was brought to emergency room with chief

complaints of:

1)pain abdomen since 7 days

2)fever since 7 days

3)vomitings since 5 days

History of present illness:

Patient was apparently alright 7 days back; then she developed -

● c/o fever since 7 days; high grade,intermittent associated with

chills and rigors; relieved with medication and associated with
myalgias, generalised weakness and easy fatiguability.
● No history of insect bite/head ache/bleeding
manifestations/rash/reeling sensation/arthralgias
● c/o abdominal pain since 7 days; spasmodic type more in
epigastrium and left hypochondrium nonradiating,aggravating
on taking food and relieved on taking medication
● c/o vomitings since 5 days, 3-5 episodes/day ,non-
projectile,non bilious, non foul smelling,non blood stained, and
contained food particles
● c/o yellowish red discolouration of urine since 1 week
● No c/o cold/cough/chest pain/dyspnoea/loose
stools/constipation
● No c/o decreased urine output/burning micturition/involuntary
micturition/hesitancy/urgency
● No c/o /haemetemesis/malaena/ haemoptysis/bleeding
gums/bleeding per rectum
 ● No c/o involuntary movements/dysphagia/hoarseness of
voice/loss of consciousness/syncopal attacks/ blurring of
vision/tingling and numbness of limbs/ear pain/ear discharge
● No c/o NSAIDS and steroid abuse

Past history:
● H/O similar complaints 20 days back and admitted in psims
hospital and diagnosed as polymenorrhoea secondary to
uterine fibroid with cervical polyp to r/o malignancy with
anaemia secondary to ? Hypersplenism with Hb-3gm% with
normocytic normochromic picture with leucopenia and 2 units
of packed RBCs transfusion done.After BT, Hb was 9.3gm%
● k/c/o Hypothyroidism since 10 yrs; on Tab.Levothyroxine 50
mcg
● H/O Malaria with Juandice and malaena 20 yrs back and 2 units
of blood transfusion 20 yrs back in view of juandice
● H/O intolerance to oral and parenteral iron 20 yrs back
● No h/o hypertension/diabetes/TB/asthma/
CVD/CKD/CAD/epilepsy

OBG history:
● Age of menarche-12 yrs;menstrual cycles-4/30
days,regular,normal flow,no clots,no dysmenorrhoea. LMP-
31/7/18
● h/o oligomenorhoic cycles since 6 yrs previously followed by
polymenorrhoea,3 cycles in last month --> 5-6 /10 days and
associated with dysmenorhoea.
● No c/o dyspareunia/white discharge

Marital life -27 yrs

 P2 L2; all FTVDs and tubectomised;P1-male child,25 yrs age and
P2-male child,23 yrs

Personal history:
Mixed diet;Normal appetite and sleep ,bowel and bladder habits
regular,no addictions

General examination:
patient is conscious and coherent

● Pallor present
● Flat and pale nails and pale palms
● Pale and bald tongue
● Dental caries present
● Dry skin+
● No venous hum
● No icterus/cyanosis/clubbing
● No Lymphadenopthy/edema
● Height:155 cm weight:40 kgs BMI:16.6
kg/m2(malnourished)

Vitals:

PR: 82 bpm,regular rhythm with normal vol.

BP: supine-120/80 mm of HG

standing-110/70 mm of HG

TEMP.:98.4 F

RR:20/min

SPO2:97%@room air
 GRBS:115 mg/dl

Systemic examination:

CVS: s1s2+, JVP normal

RS : B/L NVBS+;no added sounds

P/A :soft,tenderness in epigastrium and left

hypochondrium+,splenomegaly present 4 cm below the LCM,firm
and tender. Hepatomegaly present 3 cm below the RCM,normal
surface and tender. Bowel sounds+ 2-3/min

CNS: Higher mental functions normal and no focal neurological

deficits

HAEMOGRAM 0N ADMISSION

HAEMOGLOBIN 3.8

TWBC 3300

N-74%,L-20%,E-3%,M-3%

PCV 8.8%

PLATELET 1.5lacs/cumm
COUNT

TRBC 0.86 million/cumm

RED CELL MCV →102fl

INDICES
MCH →44.3pg
Peripharal
MCHC→43.2%
smear Dimorphic anaemia with leucopenia

Smear for MP Negative

AND PARAMAX

Reticulocyte 3%
count

Absolute retic 0.6

count

Reticulocyte 0.25(hypoproliferation of reticulocytes)

index

Blood group B positive

Serum ferritin 85 ng/ml

Viral markers HIV/HBsAg/HCV-negative

DENGUE IgG-positive,VDRL-Negative

Coombs test DCT and IDCT →positive

Total bilirubin 2.3 mg/dl (2.5mg/dl 20 days back and 1.4 mg/dl 2 days back)

Indirect bilirubin 1.3mg/dl

Direct bilirubin 1.0mg/dl

ALP 45 IU/L

SGOT 37 IU/L
SGPT 18 IU/L

TOTAL PROTEINS 5.9mg/dl

s.albumin→3.3; globulin→2.6

PT 12.3(9.1-12.1)

aPTT 22.7(24.6-35.2)

INR 1.16(1.0-1.3)

Serum folate 9.18 ng/ml(normal->5.38)

Anti nuclear 8.76 units(<20 negative)

antibodies

Vit B12 600 pg/ml

Thyroid profile T3- 0.68 Ng/ml

T4- 11.2 MCG/ml

TSH-1.58IU/ml

Blood urea 45 mg/dl

s.creatinine 0.8 mg/dl

Serum calcium 9.8mg/dl

Serum sodium 141meq/l

Serum potassium 3.4meq/l

Serum chloride 105meq/l

Stool for occult Negative
blood

CUE

RBC 1

BACTERIA 1

BLOOD 1+

PROTEIN Negative

GLUCOSE NEGATIVE

USG ABDOMEN AND PELVIS:

● Splenomegaly with minimal ascites

● Focal hypoechoic lesion in the uterine myometrium-s/o small
multiple fibroids
● Focal heteroechoic lesion in the lower uterine segment/cervical
lumen-?cervical polyp

UPPER GI ENDOSCOPY- Erosive antral gastritis

Ophthalmology :

fundus : Rt eye Lt eye

1)optic disc pinkish orange pinkish orange

&margins are &margins are

 clear and clear and distinct

distinct

2) C:D ratio 0.3 0.3

3)blood vessel Roth spots+ drusen+

4)foveal reflex + +

Gynaec referral was done and advised pap smear and planned
endometrial biopsy and cervical polypectomy

Gynaecological examination:

p/s-vaginal mucosa pale;cervix healthy

p/v-uterus mid position,normal size,mobile, non tender,free fornices

PAP SMEAR: Negative for intraepithelial lesion or malignancy

cytodiagnosis: inflammatory smear

Peripheral smear :
● Dimorphic picture
● RBC-normocytic normochromic,macrocytic microcytic and
hypochromic cells with anisopoikilocytosis with elongated cells,
tear drop cells
● WBC and platelets- normal
BONE MARROW
ASPIRATION
REPORT

MYELOID SERIES 38%

ERYTHROID 60%
SERIES

LYMPHOCYTES 2%

MONOCYTES 3%

PERLS STAIN Positive

IMPRESSION FEATURES SUGGESTIVE OF ERYTHROID HYPERPLASIA WITH

MEGALOBLASTIC ERYTHROPOIESIS