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Summerise this report
Here is a summary of the 7-page discharge report from Sree Mookambika Institute of Medical Sciences:
Discharge Summary - DEVADHAS
Hospital: Sree Mookambika Institute of Medical Sciences, Kanyakumari District
Doctor: Dr. Venston Prabu V (General Medicine)
Admission: 03-Jul-2026 | Discharge: 14-Jul-2026 (11 days)
Patient
- 69-year-old male from Vencode, Puthukadai
- Known diabetic (T2DM) for 20 years
Final Diagnoses
- Pancytopenia under evaluation - possible Aplastic Anemia
- Bone marrow dry tap (7/7/2026) - no marrow could be aspirated
- Hypothyroidism
- Type 2 Diabetes Mellitus (T2DM)
- Prostatomegaly (on Tab Tamusulosin + Dutasteride)
- Cholelithiasis (gallstones - was planned for elective cholecystectomy)
Why He Came
- 2 years of increased urinary frequency and nocturia (3-4 episodes/night)
- Previously diagnosed with UTI and Leptospirosis
- On evaluation for elective cholecystectomy, pancytopenia was incidentally found, prompting this admission for further workup
Key Investigation Results
| Test | Result | Significance |
|---|---|---|
| Hemoglobin | 10.4 g/dL | Low (anemia) |
| WBC (Total) | 2,530 cells/cumm | Very low (leucopenia) |
| Platelet Count | 0.99-1.10 lakhs/cumm | Low (thrombocytopenia) |
| Absolute Neutrophil Count | ~1,195-1,460 cells/µL | Low (neutropenia) |
| Vitamin B12 | 1,070 pg/mL | Normal/elevated |
| LDH | 255 U/L | Mildly elevated |
| Reticulocyte Count | 1.5% | Low-normal |
| Iron | 99.3 µg/dL | Low |
- Viral markers (HIV, HBsAg, HCV, Syphilis): All non-reactive
- Peripheral smear: Dimorphic anemia (normocytes + microcytes), reduced WBCs and platelets - consistent with pancytopenia
Bone Marrow Studies (Critical Findings)
- Bone marrow aspirate (07/07/26): Paucicellular (very few cells), hemodiluted - bone marrow trephine biopsy recommended
- Bone marrow biopsy (trephine): Showed only bony trabeculae and skeletal muscle fragments - no hematopoietic (blood-forming) elements seen - reported as inadequate; addendum (13/07/26) confirmed same findings - no marrow elements seen
This is consistent with either aplastic anemia or a technically inadequate sample (dry tap).
Treatment Given During Admission
- Tab Udiliv (ursodeoxycholic acid - for liver/gallstones)
- Tab Jalra M (diabetes)
- Tab Dibizide M (diabetes)
- Cap Zincosule (zinc supplement)
- Inj PAN (pantoprazole)
- Tab Thyroxine 62.5 mcg (for hypothyroidism)
- Tab Ultracet, Tab Flokind, Cremaffin syrup
- Tab Folic Acid 5mg, Livogen Z, Renerve Plus (supplements)
Discharge Situation
Medical oncology review was obtained and a repeat bone marrow biopsy was advised. However, the patient's family was not willing and requested discharge. The patient was discharged against medical advice with medications for 30 days and was strongly advised to follow up at the Medical Oncology OPD for further evaluation.
Key Takeaway
This patient has unexplained pancytopenia (all three blood cell lines reduced) with a bone marrow biopsy showing no marrow elements - a finding consistent with aplastic anemia or possibly a marrow infiltrative process. The cause remains unconfirmed as a repeat biopsy is still needed. Urgent follow-up with a hematologist/oncologist is required.
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