16yr/f with pancytopenia & fever under evaluation
16yr/f with pancytopenia & fever under evaluation
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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
TIMELINE
16 years old female studying 10th class came with the complaints of fever since 10 days ,
SOB since one week,
vomiting since 2 days
constipation ( did not pass stools ) since 4-5 days
Patient was apparently asymptomatic 3 months ago then she took covid vaccine in January 2022 ( 2nd dose ) following which she had fever high grade, continuous , which lasted for 2 to 3 days , associated with giddiness , easy fatiguability.
Patient was fine till 10 days back then she had complaints of fever, high grade, associated with chills lasted for one week and it was subsided with medication .
no h/o loose stools, vomiting , burning micturition ,cough , cold, sore throat.
C/o of SOB progressed from Grade 2 to grade 3 over last 10 days
Palpitations +
No h/o chest pain , orthopnea, pnd
C/o vomitings , non bilious, non projectile with food as content.
H/O constipation since 4-5 days ( previously bowel habits were regular )
No complaints of pain abdomen .
H/O weight loss = 10 kgs in 2 years
( 2020) : 45 kgs
July 2021 : 40 kgs
now 34kgs
REPORTS : (24/3/22)
HB : 2.4
TLC : 2400
PLT : 24000 (1.5lakh to 4.5 lakh) decreased
RBC : 1.0 million
Mcv : 106 (80-100fl)
MCHC : 50
Pcv : 09(35-45) decreased
N/k/c/o of DM, HTN, EPILEPSY, TB, ASTHMA, THYROID DISORDERS
PERSONAL HISTORY :
DIET :
BREAKFAST : till 2020 patient used to take rice to school and since 1 year patient was drinking tea with biscuits and going to school
LUNCH : school management provides lunch daily with dal and rice and eggs thrice weekly ( mid day meal programme)
EVENING : patient doesn't eat anything
DINNER : pt eats rice with curry ( bottle guard, ladies finger, etc ) doesn't drink milk, rarely consumes curd .
Consumes non veg (chicken) once in a month
APPETITE : loss of appetite since 3 days.
BOWEL & BLADDER : constipation ( did not pass stools ) since 4-5 days
Bladder habits were regular.
SLEEP : adequate
No known addictions
MENSTRUAL HISTORY :
Attained menarche 3yrs ago. Normal flow : 3-5 days bleeding, changes 1-2 pads/ day. No clots & no dysmenorrhoea
FAMILY HISTORY :
father : used to work as reliance employ, became alcohol addict since 6 yrs, drinks alcohol daily. & not working at present
MOTHER : works as daily wage labourer.
socio economic status : lower middle class ( acc to B.G prasad's classification)
GENERAL EXAMINATION :
Ht : 145cm
Wt : 34 kgs
BMI : 16.2 Kg/m2 (N-16.8-17.2)
Pallor ++
Bald tongue
No icterus, cyanosis, clubbing, lymphadenopathy, edema.
Temp : 98.6f
PR: 136 bpm
Bp : 100/40 mmhg
RR : 18cpm
Spo2 : 98% @RA
Cvs : jvp raised
Apex beat : 5th ICS . 1 1/2 inch lateral to MCL S1 s2 heard. systolic murmur + @pulmonary area, tricuspid area with carotid radiation
Parasternal haeve +
RS : BAE +, NVBS
Per ABDOMEN : mild hepatomegaly +
CNS : NAD
DIAGNOSIS : Pancytopenia &
Fever under evaluation
TREATMENT :
On 24/3/22
1) SYP. CREMAFFIN 10ml /po/HS
2) INJ. OPTINEURON 1amp in 100ml /iv/OD
3) Inj.NEOMOL 1gm i.v sos
4) TAB.DOLO 650mg po/ sos
5) Planning for 1 PRBC Transfusion
6)Soap water enema stat
7)INJ. ZOFER 4 mg / iv/BD
8) INJ.PAN 40 mg /iv/po/OD
24/3/22 :passed.stools after giving soap water enema at 8:30 pm
1 unit ( PRBC ) blood transfusion done at 9:30 pm
On 25/3/22
S : sob decreased compared to yesterday generalised weakness +
No fever spike
O : pt is c/c/c
Bp : 110/70
Pr : 98bpm
Cvs : s1s2 +
Rs : Bae +
P/A : mild hepatomegaly
A : Anemia secondary to nutritional cause ? B12 deficiency
P : TAB. DOLO 650mg /po/TID
TAB.PAN 40mg /po/OD
TAB. ZINCOVIT 1tab po/OD
INJ. ZOFER 4mg sos
Inj. NERVIGEN 1000micrograms in 100ml /NS / i.v /OD
TAB. FOLIC ACID 5mg /po/oD
TAB. OROFER XT PO /OD
26/3/22
S : c/o b/L leg pains +
SOB decreased
O :
O : pt is c/c/c
Bp : 100/70
Pr : 92 bpm
Cvs : s1s2 +
Rs : Bae +
P/A : mild hepatomegaly
A : DIMORPHIC ANEMIA with pancytopenia secondary to ? Nutritional cause
P : CST
Natural sources of B12
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