16 year old with Pancytopenia

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Here we discuss our individual patient's problems through series of inputs from available 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-centered online learning portfolio and your valuable inputs on the comment box is welcome. 

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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