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I have all 5 pages of content extracted (the last 2 images were visible in the uploaded photos and already contain the treatment/medication and addendum biopsy info). Here is the complete summary:
Discharge Summary - Patient DEVADHAS
Patient Details
| Field | Info |
|---|---|
| Name | Devadhas |
| Age/Sex | 69 Years / Male |
| MRN | 202607020312 |
| Hospital | Sree Mookambika Institute of Medical Sciences, Kanyakumari |
| Doctor | Dr. Venston Prabu. V (General Medicine) |
| Admitted | 03-Jul-2026 |
| Discharged | 14-Jul-2026 (11 days) |
Final Diagnoses
- Pancytopenia under evaluation - ?Aplastic Anemia (primary concern)
- Bone marrow dry tap (07/07/26) - no marrow obtained
- Hypothyroidism (newly diagnosed)
- Type 2 Diabetes Mellitus (T2DM) - known 20 years
- Prostatomegaly
- Cholelithiasis (gallstones)
Reason for Admission
Patient came for pre-operative evaluation before elective cholecystectomy (gallbladder removal) on 30/6/26. During evaluation, pancytopenia was discovered, so he was referred here for further workup.
Chief complaints: Increased urinary frequency and nocturia (3-4 times/night) for 2 years.
Key Investigations & Blood Results
Blood Counts (showing progressive pancytopenia)
| Parameter | Result | Normal | Status |
|---|---|---|---|
| Hemoglobin | 10.4 g/dL | 13.3 - 17.2 | LOW |
| Total WBC Count | 2,530 cells/cumm | 3700 - 9700 | LOW |
| Platelet Count (03 Jul) | 1.05 lakhs/cumm | 1.5 - 4.55 | LOW |
| Platelet Count (13 Jul) | 0.99 lakhs/cumm | 1.79 - 3.73 | LOW |
| Abs Neutrophil Count | 1,460 cells/µl | 2000 - 6700 | LOW |
| Abs Lymphocyte Count | 620 cells/µl | 1100 - 3300 | LOW |
| Reticulocyte Count | 1.5% | - | Noted |
| LDH (04 Jul) | 255 U/L | <248 | Slightly elevated |
Iron Studies (03 Jul)
- Iron: 99.3 µg/dL (Normal: 70-280) - Normal
- TIBC: 381.1 µg/dL - Normal
- Transferrin Saturation: 26% - Normal
Vitamin B12: 1,070 pg/mL - Normal
Viral Markers (06 Jul) - All Negative
- HIV 1&2: Non-reactive
- HBsAg: Negative
- HCV: Negative
- Syphilis: Non-reactive
Urine Routine: Essentially normal
Peripheral Smear Findings
- RBCs: Moderate anisopoikilocytosis - normocytes mixed with microcytes, ovalocytes, occasional macrocytes, tear drop cells, and pencil-shaped cells
- WBCs: Count reduced; neutrophils and lymphocytes in near-equal proportion; no atypical cells
- Platelets: Count reduced; seen singly scattered; manual count 1,07,000/cumm
- Impression: Dimorphic anemia + Leucopenia with neutropenia + Thrombocytopenia
Bone Marrow Studies
Aspirate & Imprint (BMA 25/26, done 07/07/26)
- Particulate paucicellular bone marrow aspirate, hemodiluted
- Only few scattered hematopoietic cells seen
- Megakaryocytes NOT seen
- No increase in blasts, granuloma, or abnormal infiltrates
- Impression: Particulate paucicellular hemodiluted bone marrow aspirate - trephine biopsy recommended
Trephine Biopsy (drawn 07/07/26, reported 10/07/26)
- Macroscopy: 3 grey-brown soft linear tissue bits (1x0.8x0.5 cm)
- Microscopy: Fragmented mature lamellar bony trabeculae + fragments of skeletal muscle and subcutaneous fat
- No hematopoietic elements seen
- Diagnosis: Bone marrow biopsy - Inadequate for opinion / No marrow elements seen
- Addendum (13/07/26): Deeper sections show similar findings - no marrow elements seen
This means the bone marrow biopsy was technically inadequate - the needle likely missed the marrow cavity, so the diagnosis of aplastic anemia could neither be confirmed nor excluded.
Treatment Given (During Admission)
| Medicine | Purpose |
|---|---|
| Udiliv 150mg | Liver/bile support (ursodeoxycholic acid) for cholelithiasis |
| Jalra M 50/500mg | Diabetes (vildagliptin + metformin) |
| Dibizide M Tablet | Diabetes (glipizide + metformin) |
| Zincosule / Tab Zincosule | Zinc supplement |
| Pan IV / Pancare 40mg | Acid suppression (pantoprazole) |
| Tab Thyroxine 62.5 mcg | Hypothyroidism |
| Ultracet | Pain |
| Flokind 0.4/0.5mg | Prostatomegaly (tamsulosin + dutasteride) |
| Cremaffin Syrup | Constipation |
Discharge Medications (30-day supply)
Udiliv, Jalra M, Dibizide M, Pancare, Thyroxine 62.5mcg, Zincosule, Flokind, Livogen Z (iron + zinc), Folic Acid 5mg, Renerve Plus (B-vitamins)
Discharge Summary Note
Patient's family (bystanders) was not willing for repeat bone marrow biopsy and requested discharge. Medical oncology review was obtained during admission - they advised repeat bone marrow biopsy. Patient was discharged against medical advice and advised to follow up at Medical Oncology OPD for further evaluation.
Key Takeaways / Clinical Concern
- This 69-year-old man has pancytopenia (all three blood cell lines low) which is a serious finding.
- The bone marrow biopsy was non-diagnostic (no marrow tissue was retrieved) - so the cause remains unconfirmed.
- The main concern being worked up is aplastic anemia vs. a malignancy (such as myelodysplastic syndrome or leukemia).
- A repeat bone marrow biopsy is strongly needed - the family must be counselled on this urgency.
- The patient has multiple other co-morbidities (diabetes, hypothyroidism, prostatomegaly, gallstones) that are being medically managed.
⚠️ Important: The patient should urgently follow up with a Medical Oncologist or Hematologist for repeat bone marrow trephine biopsy to determine the underlying cause of pancytopenia. Delaying this evaluation carries significant risk.
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