16 year old with Pancytopenia

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Case presentation : 

A 16 year old female , who is a student came with chief complaints of low grade fever since 1 week 
    Patient was  apparently normal 1 week ago then she developed  low grade fever which was intermittent type usually seen in the afternoon , not associated with any chills and rigor, associated with dry cough.
  No h/o cold , sob, vomitings, rash, loose stools,pain .
   There is h/o jaundice with fever 1year back which decreased after hospitalisation

Past history :
      No h/o hypertension, diabetes mellitus,asthma, epilepsy,thyroid 
  
Menstrual history :
       Age of menarche : 11 years
       Irregular cycles 
       She bleeds for 4 days , no clots and no dysmenorrhoea

 Personal history :
      Normal appetite
       Adequate sleep
      Bowel and bladder regular

On examination:
   Patient is conscious, coherent, cooperative moderately built and moderately nourished
    Pallor - present
     Icterus - present
    Clubbing , cyanosis, lymphadenopathy,edema - absent
 Vitals:
    Afebrile
    Pulse : 96bpm
     Bp: 110/60 mm hg
     RR : 18cycles /min
Systemic examination :
    CVS : S1, S2 heard
     Apex beat 4th ICS medial to midclavicular line
    Resp : BLAE + , NVBS
    GIT : Bowel sounds present
    CNS : No focal deficit
     P/A : Soft and non tender
              Mild splenomegaly present
   Investigations :
   Hemogram
        

Bt and Ct
            

     Thyroid profile
                
           

Blood parasite
     
LDH
   
LFT
     
Reticulocyte count 
      
RFT
     

 USG
    

ECG
    
Chest x ray
       


Provisional diagnosis :
      Pancytopenia (? B12 deficiency)
      ? Clinical Malaria
Day 1 :
 Vitals :
 Afebrile
 Bp : 110/60 mmHg
 PR : 72bpm
 Per abd : 
 Soft,  non tender, bowel sounds present
Mild splenomegaly present
Treatment :
1) Inj Falcego 120mg IV 
2) Tab doxycycline 100mg PO /BD
3) Inj Pantop 40mg IV OD
5) Inj Optineuron 1 amp in 100ml NS IV OD
6) Tab PCM 650mg PO SOS
Day 2:
Pt c/o 2episodes of Malena 
 No fever , hematuria , petechiae
Vitals :
Afebrile
PR: 72bpm
BP : 110/60 mm hg
PA : mild splenomegaly present
Investigations :
 HB : 3.8gm/dl
TC : 4000
Platelets : 46000
1 unit PRBC was transfused
Day 3:
Afebrile
BP : 100/60mm hg
PR : 87bpm
Hb : 5.3gm/dl
Platelets : 52000
2d echo :



USG :

Day 4:
Vitals :
 Afebrile
PR : 72bpm
BP : 110/70mm hg
Investigations :
 Hb : 5.5gm/dl
WBC : 4200 
Platelets : 1.5 lakh/mm3
Treatment :
1) Inj Nervigen 1amp in 100 ml NS IV OD
2) Inj Falcego 120mg IV stat
3) Tab  Pantop 40mg OD PO
4) Tab. Orofer XT PO OD

 Day 5:
 1 unit PRBC transfusion is done
  


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