About Recurrent jaundice with hepatospleenomegaly , thrombocytopenia and anaemia treatment

1. Recurrent Jaundice With
Hepatospleenomegaly ,
Thrombocytopenia and Anaemia
Submitted By
K. Goutham

2. Patient Profile Form :
Name: D.Ramana
Age: 19 years
Sex: Male
S.NO: 5109
DOA: 17/3/2014
Ward : M
Unit : Medical -1

3. Complaints :
 Jaundice
 Yellowish discolouration of Urine
 SOB grade II-III
 Headache
 Yellowish Skin
 Fever
 No Haematuria
 No altered sensorium
Family History :
Premature death of Parents with mild Hepatospleenomegaly

4. Pharmaceutical Care Plan : A 19years old male patient was admitted to general ward with
complaints of yellowish discolouration of urine from 3days , yellowish skin, shortness of breath ,
headache
Subjective Evidence : yellowish skin , yellowish discolouration of urine , No pruritus , no haematuria ,
SOB grade II-III , headache
Objective Evidence :
Lab Reports : Normal value
Urea – 88 mg <140mg
Creatinine- 20mg 20-40mg
Bilirubin- 7.0 mg 0.1-1.0mg
SGPT – 87 IU 10-40IU/L
SGOT – 50 IU 8-20 IU/L
Hb – 2.0 mg/dl 11.5-16mg/dl
Lymphocytes-36% 20-40
Monocytes-3% 2-10
ESR -42mm 1 -15mm/hr.
Eosinophils-0.4% 1-6%

5. Peripheral Smear Reports:
RBC- shows moderate anisopoikilocytosis, mostly are microcytic and some are macrocytic
occasional late
WBC – Total count with normal limits , differential counts show lymphocytes and occasional hyper
segmented , polymorphs seen.
Platelets - Less than adequate in number .
IMPRESSION- Dimorphic anaemia of severe degree with lymphocytosis and thrombocytopenia
Hemogram Report :
Dimorphic anaemia of severe degree with lymphocytosis and thrombocytopenia

6. Bone Marrow Report:
 Site of aspiration – Sternum
 Bone marrow aspirate smears are richly particulated and show uniformly hypercellular
fragments.
 Erythropoiesis- Increased in number and show mostly megaloblastic maturation.
 Myelopoiesis- Normal in number and morphology.
 M : E ratio – 1 : 4
 Megakaryopoiesis- Decrease in number and show normal morphology.
 Plasma cells and lymphocytes are normal in number.
IMPRESSION – “ Megaloblastic Anaemia”

7. Assessment :
Based on subjective evidence and
objective evidence the case was assessed as
Recurrent jaundice with
Hepatospleenomegaly ,Thrombocytopenia
and Anaemia

9. Therapeutic Care Plan :
Goals of Treatment :
 To decrease breakdown of Haemoglobin.
 To decrease the enlargement of liver and spleen.
 To decrease bilirubin levels.
 To increase platelet production.
 To reduce Fever.

10. Treatment Options:
 Cobalamin Therapy
 Folate Therapy
 Iron Supplements
 Electrolyte Supplements
 Blood Transfusion
 Antimicrobials
 Antipyretics

11. Assessment:
 Blood transfusion is advised as the patient presented with low amount of platelets due to
thrombocytopenia.
 Folate therapy and Iron supplements are suggested as the patient presented with Anaemia.
 Cobalamin therapy to increase blood production in anaemia.
 Antimicrobials are suggested to prevent infections.
 Antipyretics are given to reduce fever.

12. Day-1
 Patient is conscious and coherent
 Icterus +
 Venous hum+
 Pallor+
 Pulse Rate : 80/ min
 BP – 110/80mmHg
 CVS – S1 S2+
 RS – NVBS
 P/A – Soft
 Abdomen Scary

13. Day-2
 Patient is conscious and coherent
 Icterus +
 Venous hum+
 Pallor+
 Pulse Rate : 90/ min
 BP – 110/80mmHg
 CVS – S1 S2+
 RS – NVBS
 P/A – Soft
 Abdomen Scary

14. Day-3
 Patient is conscious and coherent
 Icterus +
 Venous hum+
 Pallor+
 Pulse Rate : 90/ min
 CVS – S1 S2+
 RS – NVBS
 P/A – Soft
 Abdomen Scary

15. Day-4
 Patient is conscious and coherent
 Icterus +
 Venous hum+
 Pallor+
 Pulse Rate : 82/ min
 CVS – S1 S2+
 RS – B/L NVBS
 P/A – Soft

16. Day-5
 Patient is conscious and coherent
 Icterus +
 Venous hum+
 Pallor+
 Pulse Rate : 100/ min
 CVS – S1 S2+
 RS – NVBS
 P/A – Soft

17. Day-6
 Patient is conscious and coherent
 Venous hum+
 Pallor+
 BP – 110/70mmHg
 Pulse Rate : 80/ min
 CVS – S1 S2+
 RS – NVBS
 P/A – Soft

18. Day-7
 Patient is conscious and coherent
 Icterus +
 C/O loose stools
 Pallor+
 BP – 110/80mmHg
 Pulse Rate : 80/ min
 CVS – S1 S2+
 RS – NVBS
 P/A – Soft

19. Day-8
 Patient is conscious and coherent
 Icterus +
 BP – 110/80mmHg
 Pulse Rate : 80/ min
 CVS – S1 S2+
 RS – NVBS
 P/A – Soft

20. Day-9
 Patient is conscious and coherent
 Icterus +
 BP – 110/80mmHg
 Pulse Rate : 78/ min
 CVS – S1 S2+
 RS – B/L NVBS
 P/A – Soft

21. Day-10
 Patient is conscious and coherent
 Icteric
 BP – 120/80mmHg
 Pulse Rate : 82/ min
 CVS – S1 S2+
 RS – B/L NVBS
 P/A – Soft

22. Goals Achieved:

23. Monitoring Parameters:
 Monitor the hemoglobin level, reticulocyte count, indirect bilirubin value, LDH level, and
haptoglobin value in patients with hemolytic anemia to determine the response to therapy.
 Urine hemoglobin and hemosiderin should be monitored to evaluate recovery in patients with
severe or intravascular haemolysis.
Problems Identified:
 Medications were not given to increase platelet production(like corticosteroids).

24. S.N
o
Dose Route Freq D1 D2 D3 D4 D5 D6 D7 D8 D9 D10
1. Tab. IFA 1tab oral TID       - - - -
2. Tab.B Complex 1tab oral OD          
3. Tab. Paracetamol 500mg oral BD     - - - - - -
4. Tab. Vit C 500mg oral OD       - - - -
5. Tab. Rantac 150mg oral BD - - - -      
6. Tab. Metrogyl 400mg oral TID - - - - - - -   
7. Tab. Ciprofloxacin 500mg oral BD - - - - - - -   
8. Inj. Optineuron 1amp IM BD - - - - - - - -  
9. Tab. Calcium 1gm oral OD - - - - - - - -  
10. Tab. Albendazole 400mg oral OD - - - - - - - -  
11. Inj. Methylcobalamin 500mcg Iv Once 1
month
- - - - - - - - - 
12. Blood Transfusion

25. Patient Counselling:
About Drugs:
1. Tab IFA: It is a nutrition supplement. It is given at a dose 400mcg/day per orally.
2. Tab Vit-C: It is a vitamin supplement given 500mg a day orally.
3. Tab Metronidazole: It is an anti bacterial given orally 400mg thrice in a day.
4. Tab Ciprofloxacin: It belongs to Fluoroquinolones 500mg orally twice a day.
5. Tab Calcium: It is a nutritional supplement given 1gm orally once a day.
6. Tab Albendazole: It is an anthelmintic given 400mg orally once a day.
7. Tab Paracetamol: It is an Antipyretic used to reduce fever given 500mg orally two times a day.
8. Inj Methylcobalamin: It is a Vitamin B12 supplement given 500mcg IV once in a month.

26. 9. Tab Rantac: It is an Antiulcerative given 150mg orally twice a day.
10. Tab B-Complex: It is a vitamin supplement given orally 1tab a day.
11. Inj. Optineuron: It is Vitamin B supplement given by IM twice a day.

27. About Disease :
Recurrent Jaundice: Jaundice is a yellow discoloration of the skin, mucous membranes, and the
whites of the eyes caused by increased amounts of bilirubin in the blood. Jaundice is a sign of an
underlying disease process.
Bilirubin is a by-product of the natural breakdown and destruction of red blood cells in the body.
The haemoglobin molecule that is released into the blood by this process is split, with the heme
portion undergoing a chemical conversion to bilirubin. Normally, the liver metabolizes and
excretes the bilirubin in the form of bile. However, if there is a disruption in this normal
metabolism and/or production of bilirubin, jaundice may result. If there is repeated episodes of
jaundice it is called Recurrent Jaundice.
Hepatospleenomegaly : Hepatospleenomegaly is the simultaneous enlargement of both
the liver (hepatomegaly) and the spleen (splenomegaly). Hepatospleenomegaly can occur as the
result of acute viral hepatitis, infectious mononucleosis, and histoplasmosis or it can be the sign of
a serious and life-threatening lysosomal storage disease. Systemic venous hypertension can also
increase the risk for developing Hepatospleenomegaly, which may be seen in those patients with
right-sided heart failure.
Liver and spleen enlargement (Hepatospleenomegaly) can occur as the result of an inherited
disorder in which the liver cannot process glucocerebroside. The build up of this substance in body
tissues can cause severe damage to the central nervous system in infants.

28. Megaloblastic Anaemia:
Megaloblastic anaemia is an anaemia (of macrocytic classification) that results from inhibition
of DNA synthesis during red blood cell production . When DNA synthesis is impaired, the cell cycle
cannot progress from the G2 growth stage to the mitosis (M) stage. This leads to continuing cell
growth without division, which presents as macrocytosis. Megaloblastic anaemia has a rather slow
onset, especially when compared to that of other anaemias. The defect in red cell DNA synthesis is
most often due to hypovitaminosis, specifically a deficiency of vitamin B12 and/or folic acid.
Vitamin B12 deficiency alone will not cause the syndrome in the presence of sufficient folate, for
the mechanism is loss of B12 dependent folate recycling, followed by folate-deficiency loss
of nucleic acid synthesis (specifically thymine), leading to defects in DNA synthesis. Folic acid
supplementation in the absence of vitamin B12 prevents this type of anaemia (although other
vitamin B12-specific pathologies continue). Loss of micronutrients may also be a cause. Copper
deficiency resulting from zinc excess from unusually high oral consumption of zinc containing
denture fixation creams has been found to be a cause.

29. Haemolytic anemia:
Haemolytic anemia is a condition that involves only the red blood cells. Haemolytic anemia is a form of
anemia due to haemolysis, the abnormal breakdown of red blood cells (RBCs), either in the blood vessels
(intravascular haemolysis) or elsewhere in the human body (extravascular).
Thrombocytopenia: Thrombocytopenia is any disorder in which there is an abnormally low amount of
platelets. Platelets are parts of the blood that help blood to clot. This condition is sometimes associated with
abnormal bleeding.
Bone marrow may not make enough platelets if have any of the following conditions:
 Aplastic anemia
 Cancer in the bone marrow, such as leukaemia
 Cirrhosis (liver scarring)
 Folate deficiency
 Infections in the bone marrow (very rare)
 Myelodysplastic syndrome (bone marrow does not make enough blood cells or makes defective cells)
 Vitamin B12 deficiency
 Use of certain drugs may also lead to a low production of platelets in the bone marrow. The most
common example is chemotherapy treatment.

30. About Life Style Modifications:
Jaundice is quite frequent in the summers and the monsoon. This is primarily due to contaminated
water or an unhygienic diet. Here are a few tips,
 Boil water before drinking. Avoid drinking water outside, which might not be purified adequately.
Only boiled water protects from bacterial infections
 Avoid oily and spicy food . These foods are difficult to digest and tend to overburden the liver. This
might result in liver damage which is manifested in the form of jaundice.
 Have a fresh fruit and boiled vegetable diet.
 Avoid eggs, meat, dry fruits, etc. Always wash the fruits and vegetables thoroughly before
consuming them.
 Vitamin B12 is naturally found in foods that come from animals, including fish, meat, poultry,
eggs, milk, and milk products.
 Fortified breakfast cereals are a particularly valuable source of vitamin B12.2 Foods rich in folate
include citrus fruits and juices and dark green leafy vegetables.