Clinical Lecture Demonstration

Group D

Our Patient

Mrs Ariyawathi

65 year old female

Piliyandala

Admitted to ward on 23.01.2014

Presented with

Shortness of breath (SOB)

LOW

LOA 6 months

Back ache

Abdominal pain

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

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)

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

Backache

Dull aching low back pain worsening in nights

Lasted 3 months

NO radiation, worsening by coughing / sneezing

NO trauma / falls recently

Abdominal pain

Right sided lower abdominal pain

Gradual onset

Mild severity

dull ache

No radiation

Persistent throughout the day

No aggravating or relieving factors

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)

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

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

Past surgical History

D&C done

Indication : post menopausal bleeding

No abnormalities in histology

No blood transfusions

Drug & Allergy

Asprin 75 mg nocte

Atrovastatin 20 mg nocte

Losartan 50 mg bd

No Food Drug or plaster allergy

Family History

No consanguineous marriage

No blood disorders in family

Strong family history of HT

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

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

Possible Differential Diagnosis

Anaemia

Deficiency

Fe

B12 FolateBlood Loss

CKD

BM Pathology

BM pathology

Aplastic anaemia

Infections : TB

Malignancies

Haematological

non haematological

Malignancies

Haematological

Multiple myeloma

Lymphoma

Leukaemia

Myelofibrosis

Meylodysplasticsyndrome

Non Haematological

Secondary deposits in bone

On Examination

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

Abdomen

Not distended

No surgical scars

Tender area in R/ illiac fossa

No organomegaly or palpable masses

No free fluids

Bowel sounds+

DRE: NAD

Spine examination

No Kyphosis /Scoliosis

No tender areas over the spine

No sacro- illiac joint tenderness

Full range of movement was present

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

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

CNS examination

Alert

Oriented in time place and person

No abnormalities detected in central & peripheral

nervous system

Fundi : NAD

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.

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

Differential diagnosis after examination

Anaemia

Deficiency

Fe

B12 FolateBlood Loss

CKD

BM Pathology

Investigations

Basic

FBC

ESR

SE

Serum Creatinine

UFR

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

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)

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

Bone marrow pathology suspected

Anaemia

Deficiency

Blood Loss

CKD

BM Pathology

Secondary BM suppression

Haematological

Multiplemyeloma

Lymphoma

Meylofibrosis

Myelodysplasicsyndrome

Leukaemia

Non Haematological

Secondary deposits in

bone

TB

Myeloma screening

Serum Protein Electrophoresis

Skeletal x –ray

Bone marrow biopsy

Serum protein electrophoresis

Skeletal survey

No Lytic lesions in the x-

ray

Skull –Lateral

Lumbo sacral – AP /LAT

Pelvic

Bone marrow Biopsy

• Easy aspiration

• Erythrocytes,

megakaryocytes,

granulocytes normal

morphology &

maturation

• No blast cells

• Plasma cells 10%

• No secondary

infiltrations noted

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

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

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

Contrast enhanced CT

Findings

• Para aortic lymph

node

enlargement

• No supra

diaphragmatic

lymph node

enlargement

• No primary

malignancies

identified

• No granuloma

Differential Diagnosis after investigations

Lymphoma

Secondary deposits in

the lymph nodes & bone

marrow

Tuberculosis

Exclude tuberculosis

Mantoux : Negative

Chest x-ray : Normal

LDH – 800(230-460)

Differential Diagnosis after investigations

Lymphoma Secondary deposits in

the lymph nodes & bone

marrow

Tuberculosis

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

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

Management of non Hodgkin's Lymphoma

Special Thanks

Dr D. Gunawardena – Consultant Haematologist

University Haematology Clinic

CSTH

Dr. A.L.L Roshan

Senior Registrar

Ward 7