Tuesday, December 31, 2013
Case 2
Day 1 (30th December)
54 y/o Chinese female known case of myelofibrosis presented with 3 episodes of haematuria.
It was not associated with painful urination, increased frequency,urgency, lower abdominal pain or fever.
There was no previous episodes.
Patient menopausal;at 50y/o
also complains of palpitation and giddyness
Otherwise no bleeding tendency; no ENT bleed,no skin bruising, no per rectal bleeding.
Myelofibrosis:
-diagnosis made 4 years ago when patient was noted to have persistently low Hb levels (9.5g/dl) on routine healthscreen examination
-patient was asymptomatic
-referred to JB for further work-up
- Bone marrow biopsy confirmed diagnosis of myelofibrosis with myeloid metaplasia and JAK 2 mutation
-has been on regular follow-up at JB; no chemoradiation done
-Regular platelet and packed cell transfusion in view of anemia and thrombocytopenia. (transfusion dependent_
Systemic: LOA and LOW(unable to quantify). BO normal; no fever night sweats
PMH/PSH: Not significant
Family Hx: leukemia(mom) and prostate ca(brother)
Social: housewife, staying w husband and children
Physical examination:
General: Pale, supraclavicular lymph node ++ (small, firm,non tender, no skin changes, normal temp), CR<2s, no cyanosis, no pedal edema/skin bruisng.
BP: 120/60 mmHg; Pulse:80beats/regular good volume;RR:18 breaths/min; Temp:afebrile
CVS: Dual Rhythm No Murmur (DRNM)
Lungs: Clear
Abdomen: soft nontender. Hepatomegaly (3 finger breaths below coastal margin, firm, smooth border, non-tender, well defined lower border); spleen palpable (10cm below costal margin, firm, smooth border, non tender, well defined border). Traube's space: dull. shiftting dullness and fluid thrills: -; bowel sounds:++
Provisional Diagnosis: Thrombocytopenia secondary to myelofibrosis
DD: UTI
Ix:
FBC: Hb: 2.7 (low), TWC:7.43; Plt: 8 (low)
LFT: albumin low (33); t.bilirubin high (80.9; Direct: 45.5 & Indirect:35.5); ALP: 441; ALT:94 GGT:114
Renal Profile: Hyponatremia (122) otherwise normal
UFEME-should have been done-
Diagnosis: Thrombocytopenia secondary to Myelofibrosis
Plan:
1. Transfuse 2unit Packed Cells
2.Transfuse 4 units plt
3.Call blood bank MO and confirm availibility
4. IV lasix 40mg in between transfusion
5. Three was CBD inserted: Noted haematuria
6. Cont old meds:
-T Danazol 200mg BD
-T Defiprone 2Tabs
- T Bcomplex 1/1 OD
-T folate 1/1 OD
7. Obtain post transfusion Hb.
8. w/o for bleeding tendency
Documentation
Called blood bank MO: packed cells available. however only 2 units plt available.
Discussed with Medical MO: to transfuse 2 plt units and 2 packed cell unit first and the remaining plt units tmrw.
Documentation
MO blood bank called: 4 units plt available.
Discussed with Medical MO: to transfuse 4 units plt and 2 packed cells.
Transfused 4 units plt and one unit packed cells over night.
IV lasix given in between transfusion. Patient well, vital signs stable did not develop any transfusion reaction.
Day 2 (31st December)
<Morning REVIEW>
<seen by MO (name)>
Post transfusion: 4 units plt and 1 packed cells
Patient well. there are no complains of bleeding. Urine bag is clear. no haematuria. no complains of transfusinon reaction.
Patient requested to remove CBD
On examination:
General: Pale, supraclavicular lymph node ++ (small, firm,non tender, no skin changes, normal temp), CR<2s, no cyanosis, no pedal edema/skin bruisng.
BP: 126/60 mmHg; Pulse:88beats/regular good volume;RR:18 breaths/min; Temp:afebrile
CVS: Dual Rhythm No Murmur (DRNM)
Lungs: Clear
Abdomen: soft nontender. Hepatomegaly (3 finger breaths below coastal margin, firm, smooth border, non-tender, well defined lower border); spleen palpable (10cm below costal margin, firm, smooth border, non tender, well defined border). Traube's space: dull. shiftting dullness and fluid thrills: -; bowel sounds:++
Ix:
FBC: -not traced-
LFT: albumin low (29); t.bilirubin high (72.3; Direct: 39.8 & Indirect:32.5); ALP: 396; ALT:88 GGT:103
Plan:
1. complete transfusion of packed cells
2. trace FBC & repeat FBC after completion of transfusion
3.IV Vit K 10mg OD
4.Cont old meds:
-T Danazol 200mg BD
-T Despriprone 2Tabs
- T Bcomplex 1/1 OD
-T folate 1/1 OD
5. w/o for bleeding signs
Documentation
second packed cell transfused
<Afternoon Review>
<seen by MO>
Post transfusion: 4 units plt and 2 packed cells
Patient well. there are no complains of bleeding. Urine bag is clear. no haematuria. no complains of transfusinon reaction.
patient requested to remove CBD. informed patient on the need to keep CBD. Patient understood.
Plan
1. repeat FBC after completion of transfusion
3.IV Vit K 10mg OD
4.Cont old meds:
-T Danazol 200mg BD
-T Despriprone 2Tabs
- T Bcomplex 1/1 OD
-T folate 1/1 OD
5. w/o for bleeding signs
<THIRD DAY REVIEW>
seen by MO & specialist (name)
Day 3 (1st January)
<Morning REVIEW>
<seen by MO (name)>
Post transfusion: 4 units plt and 2 packed cells
Patient well. there are no complains of bleeding. Urine bag is clear. no haematuria. no complains of transfusinon reaction.
On examination:
General: Pale, supraclavicular lymph node ++ (small, firm,non tender, no skin changes, normal temp), CR<2s, no cyanosis, no pedal edema/skin bruisng.
BP: 126/60 mmHg; Pulse:88beats/regular good volume;RR:18 breaths/min; Temp:afebrile
CVS: Dual Rhythm No Murmur (DRNM)
Lungs: Clear
Abdomen: soft nontender. Hepatomegaly (3 finger breaths below coastal margin, firm, smooth border, non-tender, well defined lower border); spleen palpable (10cm below costal margin, firm, smooth border, non tender, well defined border). Traube's space: dull. shiftting dullness and fluid thrills: -; bowel sounds:++
Ix:
FBC:
LFT:
Plan:
1. Remove CBD
2. trace FBC
3.IV Vit K 10mg OD
4.Cont old meds:
-T Danazol 200mg BD
-T Despriprone 2Tabs
- T Bcomplex 1/1 OD
-T folate 1/1 OD
5. w/o for bleeding signs
6. KIV discharge if Hb>8d/dl and platelet>20
Evening Review
Noted minimal spotting in pampers. Possible haematuria.
<Traced FBC>
Hb:4.1g/dL;TWC:4.0;Plt:17
Discussed with MO
Plan:
-To transfuse 4units Packed cells; two units today then two units coming morning. w/o for transfusion reaction
-FFP if rebleed.
-Monitor pad chart
-USG liver to rule out cirrhosis
-Cont old meds:
-T Danazol 200mg BD
-T Despriprone 2Tabs
- T Bcomplex 1/1 OD
-T folate 1/1 OD
w/o for bleeding signs
- KIV discharge if Hb>8d/dl and platelet>20
Documentation: Transfused two units packed cells. w/o for transfusion reaction
Day 4 (2nd January)
<Morning REVIEW>
<seen by MO (name)>
Post transfusion: 4 units plt and 4 packed cells
Patient well. there are no complains of bleeding. Pampers no spotting
On examination:
General: Pale, supraclavicular lymph node ++ (small, firm,non tender, no skin changes, normal temp), CR<2s, no cyanosis, no pedal edema/skin bruisng.
BP: 120/64 mmHg; Pulse:80beats/regular good volume;RR:18 breaths/min; Temp:afebrile
CVS: Dual Rhythm No Murmur (DRNM)
Lungs: Clear
Abdomen: soft nontender. Hepatomegaly (3 finger breaths below coastal margin, firm, smooth border, non-tender, well defined lower border); spleen palpable (10cm below costal margin, firm, smooth border, non tender, well defined border). Traube's space: dull. shiftting dullness and fluid thrills: -; bowel sounds:++
Ix:
FBC:
Plan:
Transfuse 4units of plt and review fbc tmrw
Cont old meds:
-T Danazol 200mg BD
-T Despriprone 2Tabs
- T Bcomplex 1/1 OD
-T folate 1/1 OD
w/o for bleeding signs
KIV discharge if Hb>8d/dl and platelet>20
Cont follow up at JB as planned (7/1)
Repeat FBC after completion of transfusion today.
If discharge TCA at MOPD at 3/12 with ultrasound report
Day 5 (3rd January)
<Morning REVIEW>
<seen by MO (name)>
Post transfusion: 8 units plt and 4 packed cells
Patient well. there are no complains of bleeding. Pampers no spotting
On examination:
General: Pale, supraclavicular lymph node ++ (small, firm,non tender, no skin changes, normal temp), CR<2s, no cyanosis, no pedal edema/skin bruisng.
BP: 120/64 mmHg; Pulse:80beats/regular good volume;RR:18 breaths/min; Temp:afebrile
CVS: Dual Rhythm No Murmur (DRNM)
Lungs: Clear
Abdomen: soft nontender. Hepatomegaly (3 finger breaths below coastal margin, firm, smooth border, non-tender, well defined lower border); spleen palpable (10cm below costal margin, firm, smooth border, non tender, well defined border). Traube's space: dull. shiftting dullness and fluid thrills: -; bowel sounds:++
Ix:
FBC: 8.8g/dL;TWC:5.2;Plt:5
Plan:
-transfuse 2 units plts
-review fbc cm
Cont old meds:
-T Danazol 200mg BD
-T Despriprone 2Tabs
- T Bcomplex 1/1 OD
-T folate 1/1 OD
w/o for bleeding signs
KIV discharge if Hb>8d/dl and platelet>20
Cont follow up at JB as planned (7/1)
Repeat FBC after completion of transfusion today.
If discharge TCA at MOPD at 3/12 with ultrasound report
Day 6 (4th January)
<Morning REVIEW>
<seen by MO (name)>
Post transfusion: 8units plt and 6packed cells
Patient well. there are no complains of bleeding. Pampers no spotting
On examination:
General: Pale, supraclavicular lymph node ++ (small, firm,non tender, no skin changes, normal temp), CR<2s, no cyanosis, no pedal edema/skin bruisng.
BP: 120/64 mmHg; Pulse:80beats/regular good volume;RR:18 breaths/min; Temp:afebrile
CVS: Dual Rhythm No Murmur (DRNM)
Lungs: Clear
Abdomen: soft nontender. Hepatomegaly (3 finger breaths below coastal margin, firm, smooth border, non-tender, well defined lower border); spleen palpable (10cm below costal margin, firm, smooth border, non tender, well defined border). Traube's space: dull. shiftting dullness and fluid thrills: -; bowel sounds:++
Ix:
FBC:7.2g/dL;TWC:4.2;Plt:9
Plan:
transfuse 2 units plt and review fbc cm
Cont old meds:
-T Danazol 200mg BD
-T Despriprone 2Tabs
- T Bcomplex 1/1 OD
-T folate 1/1 OD
w/o for bleeding signs
KIV discharge if Hb>8d/dl and platelet>20
Cont follow up at JB as planned (7/1)
Repeat FBC after completion of transfusion today.
If discharge TCA at MOPD at 3/12 with ultrasound report
Day 7 (5th January)
<Morning REVIEW>
<seen by MO (name)>
Post transfusion: 4 units plt and 4 packed cells
Patient well. there are no complains of bleeding. Pampers no spotting
On examination:
General: Pale, supraclavicular lymph node ++ (small, firm,non tender, no skin changes, normal temp), CR<2s, no cyanosis, no pedal edema/skin bruisng.
BP: 120/64 mmHg; Pulse:80beats/regular good volume;RR:18 breaths/min; Temp:afebrile
CVS: Dual Rhythm No Murmur (DRNM)
Lungs: Clear
Abdomen: soft nontender. Hepatomegaly (3 finger breaths below coastal margin, firm, smooth border, non-tender, well defined lower border); spleen palpable (10cm below costal margin, firm, smooth border, non tender, well defined border). Traube's space: dull. shiftting dullness and fluid thrills: -; bowel sounds:++
Ix:
FBC:
LFT:
Plan:
Cont old meds:
-T Danazol 200mg BD
-T Despriprone 2Tabs
- T Bcomplex 1/1 OD
-T folate 1/1 OD
w/o for bleeding signs
KIV discharge if Hb>8d/dl and platelet>20
Cont follow up at JB as planned (7/1)
Repeat FBC after completion of transfusion today.
If discharge TCA at MOPD at 3/12 with ultrasound report
Tuesday, December 24, 2013
Case 1 (Day 1: 22/12/2013)
Patient:
56 y/o Malay lady known case of hypertension, diabetes and End Stage Renal Failure presented with :
- progressively worsening shortness of breath 3/7 days
- bilateral lower limb swelling 3/7 days
- not compliant to fluid restriction
On Examination:
BP: 130/60 mmHg
Pulse: 80 beats/min regular volume and good strength
Respiratory rate: 22 breaths/min (tachypenic)
Temperature: 37.2 degree celcius (afebrile)
CVS: apex displaced (at 6 intercostal space). dual rhythm no murmur
Respiratory Examination: Bibasal crepitations.
Abdomen : Distended. soft non tender. (have not done fluid thrill & shiffing dullness as patient is uncomfortable)
Lower limbs: pitting edema up to the shin.
Provisional diagnosis: Fluid retention secondary to poor compliance to fluid restriction
In this patient on admission, i would like to order for the following:
1. Renal Profile and FBC
2. Arterial Blood Gas: Patient is breathless, has ESRF this maybe due to metabolic acidosis.
3. Chest X-ray
4. ECG: patient is breathless and has history DM and HT. she might be having atypical MI
Results:
Renal Profile: Urea (39.5) Creatinine (1282) sodium (131) potassium (5.1)
FBC: Hb (6.8); TWC (21.87; Neutrophilia); Platelet (503)
Chest x-ray: Cardiomegaly, bilateral blunting of costo and cardiophrenic angle
Cardiac enzyme: Normal
ECG: Atrial fibrilation
Plan:
1. IJC insertion for Haemodialysis
2. Start IV Frusemide 20mg stat then TDS
3. Nasal Prongs 3L oxygen per minute
4. continue other medications :
- T CaCO3 500mg TDS
- T Ferous fummarate 400 mg BD
- s/c actrapid 4 units if GM >10mmol/L
Patient went for haemodialysis.
<post haemodialysis>
Ix: ECG review by MO: No AF only atrial ectopy
56 y/o Malay lady known case of hypertension, diabetes and End Stage Renal Failure presented with :
- progressively worsening shortness of breath 3/7 days
- bilateral lower limb swelling 3/7 days
- not compliant to fluid restriction
On Examination:
BP: 130/60 mmHg
Pulse: 80 beats/min regular volume and good strength
Respiratory rate: 22 breaths/min (tachypenic)
Temperature: 37.2 degree celcius (afebrile)
CVS: apex displaced (at 6 intercostal space). dual rhythm no murmur
Respiratory Examination: Bibasal crepitations.
Abdomen : Distended. soft non tender. (have not done fluid thrill & shiffing dullness as patient is uncomfortable)
Lower limbs: pitting edema up to the shin.
Provisional diagnosis: Fluid retention secondary to poor compliance to fluid restriction
In this patient on admission, i would like to order for the following:
1. Renal Profile and FBC
2. Arterial Blood Gas: Patient is breathless, has ESRF this maybe due to metabolic acidosis.
3. Chest X-ray
4. ECG: patient is breathless and has history DM and HT. she might be having atypical MI
Results:
Renal Profile: Urea (39.5) Creatinine (1282) sodium (131) potassium (5.1)
FBC: Hb (6.8); TWC (21.87; Neutrophilia); Platelet (503)
Chest x-ray: Cardiomegaly, bilateral blunting of costo and cardiophrenic angle
Cardiac enzyme: Normal
ECG: Atrial fibrilation
Plan:
1. IJC insertion for Haemodialysis
2. Start IV Frusemide 20mg stat then TDS
3. Nasal Prongs 3L oxygen per minute
4. continue other medications :
- T CaCO3 500mg TDS
- T Ferous fummarate 400 mg BD
- s/c actrapid 4 units if GM >10mmol/L
Patient went for haemodialysis.
<post haemodialysis>
Patient complains persistent breathlessness and lower limb swelling . Not improving despite having dialysis and frusemide.
On examination:
BP: 110/60
Respiratory rate:21 breaths/min
Pulse: 86 beats;regular
CVS: Dual rhytm no murmur
Respiratory system: bilateral crepitations
Abdomen: distended; soft non tender
Lower limbs: pitting up to mid shin
Ix: ECG review by MO: No AF only atrial ectopy
Plan:
Repeat renal profile (awaiting results)
KIV transfuse one unit packed cells in view of low Hb
Increase IV frusemide t0 40mg TDS
post dialysis
renal profile was as below:
Parameters
|
Values
|
Normal
range
|
Urea
|
30.0 mmol/L
|
2.8-7.8
mmol/L
|
Sodium
|
131
mmol/L
|
135-145
mmol/L
|
Potassium
|
4.5 mmol/L
|
3.5-5.1 mmol/L
|
Creatinine
|
1020umol/L
|
61-124umol/L
|
Chloride
|
97
|
93-108 mmol/L
|
Phosphate
|
2.52
|
0.81-1.45
mmol/L
|
Corrected Calcium
|
2.23
|
2.20-2.65 mmol/L
|
Magnesium
|
1.04
|
Post haemodialysis renal profile showed a reduction in
urea, potassium and creatinine levels.
She was transfused with one unit packed cells after the
dialysis.
Day 1 (24th December 2013)
Patient still complains of breathlessness and lower limb
edema. On examination, she was tachypenic, blood pressure 110/60mmHg, pulse
rate: 80 beats/min with good volume and regular rate. On auscultation, there
were bibasal crepitations audible. She was planned for a second haemodialysis
to be scheduled on the 25th of December in view of her raised urea
levels and breathlessness.
Day 2 (25th December 2013)
Patient went for haemodialysis. Post dialysis renal
profile is as below:
Parameters
|
Values
|
Normal
range
|
Urea
|
20.0mmol/L
|
2.8-7.8
mmol/L
|
Sodium
|
133
mmol/L
|
135-145
mmol/L
|
Potassium
|
4.3 mmol/L
|
3.5-5.1 mmol/L
|
Creatinine
|
782umol/L
|
61-124umol/L
|
Chloride
|
96
|
93-108 mmol/L
|
Phosphate
|
2.45
|
0.81-1.45 mmol/L
|
Corrected Calcium
|
2.25
|
2.20-2.65 mmol/L
|
Magnesium
|
1.15
|
The renal profile shows a reduced level of urea and
creatinine. Clinically patient is improving. Her breathlessness has improved.
On examination, there are occasional bibasal crepitations and pitting edema up
to the mid shin.
Day 3 (26th December 2013)
Patient feels that there is slight improvement in regards
to her breathlessness as compared to yesterday. On examination, she was not
tachypenic, blood pressure 112/58mmHg, pulse rate: 84 beats/min with good
volume and regular rate. There are
occasional bibasal crepitations and pitting edema up to the mid shin. She was scheduled for another haemodialysis
the next day. A repeat FBC showed a Hb of 8.1 gd/L. She was planned for another
unit of packed cell transfusion after her third dialysis.
Day 4 (27th December 2013)
Patient feels breathless occasionally. On examination,
she was not tachypenic, blood pressure 106/62mmHg, pulse rate: 80 beats/min
with good volume and regular rate. there are occasional bibasal crepitations
and pitting edema up to the mid shin.
She underwent her third haemodialysis and blood sample were taken for
FBC and Renal Profile. She was scheduled to be discharge.
DISCHARGE
PLAN, COUNSELLING AND MOCK PRESCRIPTION
Discharge
Plan
The final diagnosis by the hospital: Fluid retention
secondary to fluid overload secondary to poor compliance to fluid
restriction.
Discharge plan was as follow:
1. Advise
patient on restriction of fluid <1L/day
2. Patient
to follow-up for dialysis at her own centre at Tanah Merah.
3. Patient
to come again in one month time for inspection of IJC and KIV change
4. For
infective screen at Tanah Merah
5. Discharge
patient with:
- Tablet
haematinics
- CaCO3
500mg TDS
- Tablet
frusemide 400mg OD
- Tablet
ranitide 150mg BD
- Anti-hypertensives
were discontinued in view of good blood pressure control throughout hospital
admission.
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