16 year old pancytopenia with fever under evaluation
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TIMELINE
16 year old female studying in 10th class came to OPD with
Chief Complaints of
1. Fever since 10days
2.shortness of breath since 1week
3. Constipation since 4-5 days
4.Vomiting since 2 days.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 10 days back then she had fever high grade which is continuous in onset gradually progressive which lasted for 2 to 3 days , associated with giddiness , easy fatiguability , chills lasted for one week
It was subsided with medication .
no h/o loose stools, 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
PAST HISTORY:
No history of chronic blood loss like RTA or Hookworm infections
No similar complaints in the past
N/k/c/o of DM, HTN, EPILEPSY, TB, ASTHMA, THYROID DISORDERS
PERSONAL HISTORY:
Diet - mixed
Appetite - loss of appetite
Bowel movement were irregular
Bladder movement were regular
Sleep - adequate
Addictions - nil
FAMILY HISTORY:
No history of Hemoglobinopathies
GENERAL EXAMINATION:
Patient is conscious , cohere
Ht : 145cm
Wt : 34 kgs
BMI : 16.2 Kg/m2 (N-16.8-17.2)
Pallor ++ (24/02/2022)
28/03/2022 Pallor - absent
Hyperpigmenation of knuckles
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
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 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
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
(26/3/22)
HB : 4.3
TLC :1900
(27/3/22)
HB : 4.2
TLC : 2900
(28/3/22)
HB :4.5
TLC :5700
PLT : 70,000
A : DIMORPHIC ANEMIA with pancytopenia secondary to ? Nutritional cause
P : CST
Sources of B12
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