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Anaemia
- 2. Our Patient Mrs Ariyawathi 65 year old female Piliyandala Admitted to ward on 23.01.2014
- 3. Presented with Shortness of breath (SOB) LOW LOA 6 months Back ache Abdominal pain
- 4. SOB: gradually worsening for 6 months Initially she could climb up small slopes and function day to day activities For last 3 months condition worsen Now cannot walk even few steps inside house and perform her day to day activities due to breathlessness NO SOB at rest (NYHA III) NO cough , sputum production or wheezing episodes NO chest pain, palpitation, orthopnoea, PND, ankle swelling
- 5. Easy fatigability & Lethargy 6 months worsening lethargy Preferred sleeping most time NO lump observed in the neck, cold intolerance, constipation ( Hypothyroidism) NO recurrent infections, sore throat, oral ulcers (Leukopenia) NO bleeding manifestations ( Thrombocytopenia)
- 6. LOA & LOW Only small quantity Nausea+ NO vomiting, dysphagia & odynophagia Has noticed clothes become loose : BW not measured recently Has noticed drenching night sweats No fever
- 7. Backache Dull aching low back pain worsening in nights Lasted 3 months NO radiation, worsening by coughing / sneezing NO trauma / falls recently
- 8. Abdominal pain Right sided lower abdominal pain Gradual onset Mild severity dull ache No radiation Persistent throughout the day No aggravating or relieving factors
- 9. Vegetarian ( Deficiency anaemia?) NO pica NO forgetfulness / lower limb weakness NO steatorrhea, chronic diarrheoa ( malabsorption) NO PR bleeding, PV bleeding, haematemesis, maleana, heamaturia ( Blood Loss) Not noticed yellowish discoloration of eyes or dark urine ( heamolysis)
- 10. UOP : normal has noticed frothy urine for past 1 month No Smoky urine ( no active sediments) NO other urinary symptoms NO skin rashes, joint ache
- 11. Past medical History NO TB Solid organ or Haematological Malignancy No Autoimmune disorder Hypertension + past 7 years - incidental 2 episodes of hospital admissions with high BP NO IHD, Angina, strokes or TIA On Losartan 50 mg bd Follow up at pvt sector No DM ,Dyslipideamia Gyneacological Hx: P3 C3 NVD
- 12. Past surgical History D&C done Indication : post menopausal bleeding No abnormalities in histology No blood transfusions
- 13. Drug & Allergy Asprin 75 mg nocte Atrovastatin 20 mg nocte Losartan 50 mg bd No Food Drug or plaster allergy
- 14. Family History No consanguineous marriage No blood disorders in family Strong family history of HT
- 15. Social history Married Mother of 5 children Husband had a stroke 8 months back Both living with youngest daughter No income Total depend on daughter : helped financially by children ADL : greatly impaired due to SOB Good hygiene at home Hospital : Piliyandala – 15 mins drive
- 16. What are we dealing with? A 65 year old lady Known patient with HT on Rx Worsening Excertional dyspnoea LOA LOW Drenching night sweats Lower back pain Right sided lower abdominal pain Non smoky Frothy urine
- 17. Possible Differential Diagnosis Anaemia Deficiency Fe B12 Folate Blood Loss CKD BM Pathology
- 18. BM pathology Aplastic anaemia Infections : TB Malignancies Haematological non haematological
- 20. On Examination
- 21. General examination Thin build, ill looking, elderly female Not dyspnoeic Afebrile Pale+, not icteric, or cyanosed No angular stomatitis, glossitis, oral ulcers No nail changes : Koilonoichia, leukonoichia No cervical , axillary, inguinal lymphadenopathy No skin rashes or ecchimotic patches No B/L ankle oedema No peripheral stigmata of CkD – periorbital oedema, dry skin, half half nails Breast : NAD
- 22. Abdomen Not distended No surgical scars Tender area in R/ illiac fossa No organomegaly or palpable masses No free fluids Bowel sounds+ DRE: NAD
- 23. Spine examination No Kyphosis /Scoliosis No tender areas over the spine No sacro- illiac joint tenderness Full range of movement was present
- 24. CVS Pulse :88 bpm regular good volume all peripheral pulses present B.P : 130/90mmHg Apex : 5th IC space mid clavicular line Dual rhythm no murmurs
- 25. RS R/R : 18 / min Chest movements normal B/L Trachea midline Vocal Fremitus : Normal Percussion note : resonant 3 zones B/L B/L vesicular breathing No added sounds
- 26. CNS examination Alert Oriented in time place and person No abnormalities detected in central & peripheral nervous system Fundi : NAD
- 27. Summery A 65 year old known hypertensive female for past 7 years, presented with progressive exertional dyspneoa (NYHA III) , LOA,LOW, Malaise and lethargy for 6 months duration. With 3 months history of dull lower back pain & Lower abdominal pain. Few weeks of drenching night sweats without fever. On examination she was pale not icteric with no peripheral lymphadenopathy having RIF tenderness without organomegaly and unremarkable systemic examination.
- 28. Problem List Acute Excertional dyspnoea with constitutional symptoms Back ache Pallor RIF pain Chronic Hypertension Impaired quality of life Socio economic impact on daughter with caring 2 elders
- 29. Differential diagnosis after examination Anaemia Deficiency Fe B12 Folate Blood Loss CKD BM Pathology
- 30. Investigations Basic FBC ESR SE Serum Creatinine UFR
- 31. Patient’s Results FBC Parameter Findings WBC 7.6 * 103 / uL Neu 3.4 * 103 / uL Lymphocytes 2.9* 103 / uL Monocytes 1* 103 / uL Basophill 0.1* 103 / uL Eosinophill 0.2* 103 / uL Hb 9.6 g/dl HCT 31.7% MCV 90 fl MCH 28 pg RDW 14.6 % PLT 37 *103 / uL
- 32. FBC suggested bicytopenia Blood picture done • RBC- Normochromic Normocytic • Few round macrocytes, polychromatic cells, occasional nucleated RBC.no tear drop cells • Marked rouleaux formation • No evidence leuco-erythroblastic blood picture • WBC: no blast cells, left shift, atypical cells • PLT: moderate thrombocytopenia .no megakaryocytes Reticulocyte count: 1.2% (normal)
- 33. ESR -122/ 1st hour SE LFT normal Creatinine eGFR UFR ALP Ca+ normal PO4 Parameter Result Albumin + Urine reducing substances Nil Pus cells 3-5/ hpf Red Cells Nil Epithelial cells Nil Crystals Nil Casts Nil
- 34. Bone marrow pathology suspected Anaemia Deficiency Blood Loss CKD BM Pathology
- 36. Myeloma screening Serum Protein Electrophoresis Skeletal x –ray Bone marrow biopsy
- 38. Skeletal survey No Lytic lesions in the x- ray Skull –Lateral Lumbo sacral – AP /LAT Pelvic
- 39. Bone marrow Biopsy • Easy aspiration • Erythrocytes, megakaryocytes, granulocytes normal morphology & maturation • No blast cells • Plasma cells 10% • No secondary infiltrations noted
- 40. Multiple Myeloma Diagnosis Criteria Monoclonal gamma globulinaemia >30g/l serum paraprotein Bone marrow increase plama cells >20% Bone lesions Pepper pots apperance-osteolitic areas without evidance of surrounding osteolytic or osteosclerotic reactions
- 41. USS abdomen • RIF tenderness exclude any pathology • To exclude malignancy in abdomen which can cause deposits in bone • Exclude hepatosplenomeg aly Findings R adenexial mass ? Ovarian tumour
- 42. CA 125 23 U/ml CA 125 use as one of several tests to diagnose ovarian CA Or Monitoring of people with well known ovarian malignancies
- 44. Findings • Para aortic lymph node enlargement • No supra diaphragmatic lymph node enlargement • No primary malignancies identified
- 45. Differential Diagnosis after investigations Lymphoma Secondary deposits in the lymph nodes & bone marrow Tuberculosis
- 46. Exclude tuberculosis Mantoux : Negative Chest x-ray : Normal LDH – 800(230-460)
- 47. Differential Diagnosis after investigations Lymphoma Secondary deposits in the lymph nodes & bone marrow Tuberculosis
- 48. Further management Patient referred to Haematology follow up Planned ultrasound guided lymph node biopsy – results awaiting Continued same medication for hypertension Symptomatic management Pain : PCM 1 g SOS Nutritional advices given to caregivers Nausea – metoclopramide 10mg tds
- 49. Lymphoma Hodgkin`s • Majority young adults • Extra nodal manifestation is rare • Non Heterogenic • Present with painless rubbery lymph nodes • Lymph node biopsy has REED STERNBERG CELLS • curable Non Hodgkin`s • Majority older age • Heterogenic presentation • Extra nodal manifestations common • Present with extra nodal disease • FBC,Blood pic,CECT,lymph node biopsy,BM aspiration
- 50. Management of non Hodgkin's Lymphoma
- 51. Special Thanks Dr D. Gunawardena – Consultant Haematologist University Haematology Clinic CSTH Dr. A.L.L Roshan Senior Registrar Ward 7