16 yr old female with severe anaemia
CBBLE UDHC Similar case
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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 10 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 10 days ( previously bowel habits were regular )
No complaints of pain abdomen .
H/O weight loss of 10 kgs in 2 years
9th class( 2020) : 45 kgs
July 2021 : 40 kgs
now 34 kgs
Outside REPORTS : (24/3/22)
HB : 3.1
TLC : 3800
PLT : 24000
RBC : 1.0 million
Mcv : 106
MCHC : 50
Pcv : 09
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 10 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
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
https://youtu.be/ql8_7pfOd34
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
Subjective : sob decreased compared to yesterday
generalised weakness +
No fever spike
Objective : pt is c/c/c
Bp : 110/70
Pr : 98bpm
Cvs : s1s2 +
Rs : Bae +
P/A : mild hepatomegaly
Assessment : Anemia secondary to nutritional cause ? B12 deficiency
Plan : 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 : 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 : continuing same treatment ( CST )
27/3/22
S : c/o fever ++
c/o b/L leg pains decreased
SOB decreased
O : pt is c/c/c
Temp : 99.2
Bp : 100/70
Pr : 116 bpm
Cvs : s1s2 +
Rs : Bae +
P/A : mild hepatomegaly
A : DIMORPHIC ANEMIA with pancytopenia secondary to ? Nutritional cause
P : CST
28/3/22
S : no fever spikes
O : pt is c/c/c
Temp : 98.8
Bp : 100/70
Pr : 112 bpm
Cvs : s1s2 +
Rs : Bae +
P/A : mild hepatomegaly
A : DIMORPHIC ANEMIA with pancytopenia
P : CST
