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