60 year old male with ruptured perineal abscess Pancytopenia

60 year old male with ruptured perineal abscess Pancytopenia - ?aplastic anemia

September 16, 2022

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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.This E-blog also reflects my patient's centred online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

REFERRAL FROM SURGERY IN VEIW OF PANCYTOPINIA

A 60yr old male patient came to surgery opd with cheif complaints of ulcer on perineal region

HOPI:

Patient was apparently asymptomatic 2 months back, then he developed swelling which was sudden in onset, gradually progresive; which was followed by formation of pus point and then discharge of seropurulent discharge; ultimately leading to formation of ulcer.

No history of fever, constipation and loose stools

Past history:

Not a k/c/o DM,TB, HTN Asthma,CAD, Epilepsy and Thyroid disorders.

Personal history:

Diet: mixed

Appetite: decreased since 2months

Sleep: decreased due to pain since 2months

Bowels: regular

Micturition: Normal

Addictions: alcoholic (50ml per day), regular smoker (18 beedis per day)since 45yrs, stopped since 2month

Family history: No Comorbidities in family members.

General examination:

Patient is conscious and cooperative, Oriented to time, place and person.

Moderately built and nourished.

Vitals:

Afebrile

PR: 84bpm

Bp: 120/80mmhg

RR:19 cpm

SpO2: 97%

No Pallor, icterus, cyanosis, and lymphadenopathy.

Edema: pitting type

Clubbing: present

Systemic examination:

CVS: S1 S2 sounds heard

RS: BAE+,clear

P/A :Soft ,non tender ,no organomegaly

CNS:NAD

COURSE OF TREATMENT

A 60-year male clinically presented to the causality with the above-mentioned complaints. Upon admission, necessary investigations were done. His initial workup showed Hb 5.3gm/dl; TLC 1100 cells/mm³; platelet count 65000 lakhs/mm³. He was taken over by the Department of general medicine from the department of general surgery.

Usg abdomen was done on 15/09/2022 which showed findings of:

Liver of normal size and echotexture.

The spleen of 11.3 cm with normal size and echotexture.

Right kidney 8.6×4.1 cms and left kidney 8.4×4.4 cms with normal size and echotexture with corticomedullary junction differentiation maintained and PCS was normal.

Impression: normal.

Pus for culture and sensitivity was sent from the perineal abscess; which showed growth of Proteus mirabilis and E. coli on 16/09/2022.

On 16/09/2022 his Hb was 3.7 gm/dl; TLC 100 cells/mm³; platelet count 38000 lakhs/mm³. One unit of 450ml whole blood transfusion was done on 17/09/2022 and the transfusion was uneventful. Post transfusion after 24 hours repeat hemogram showed Hb of 6.0 gm/dl; TLC 200 cells/mm³; platelet count 60,000 lakhs/mm³. Urine for hence Jones proteins and serum electrophoresis has been sent and reports were awaiting. He was advised for bone marrow aspiration and biopsy, but the patient has been refused the same and he was discharged as LAMA.