16 year old with pancytopenia and 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

16 year old female studying in 10th class came to OPD with
Timeline

CHIEF COMPLAINTS OF:

Fever since 10 days
Shortness of breath since 1 week
Constipation since 4-5 days
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 .   

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 . 

No h/o loose stools, burning micturition ,cough , cold, sore throat.

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 history of previous blood transfusion
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 and bladder - constipation since 4-5days
Bladder movement were regular
Sleep - adequate
Addictions - no

FAMILY HISTORY:

No history of hemoglobinopathies

GENERAL EXAMINATION:

Pt is conscious , coherent , co-operative nd well oriented to time , place nd person

Ht : 145cm 
Wt : 34 kgs
BMI : 16.2 Kg/m2 (N-16.8-17.2)

Pallor ++ (24/3/22)
on (28/3/22)
Hyperpigmenation of knuckles


Koilonychia
No icterus, cyanosis, clubbing, lymphadenopathy, edema. 

Temp : 98.6f
PR: 136 bpm
Bp : 100/40 mmhg
RR : 18cpm
Spo2 : 98% @RA

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( B12 deficiency secondary to nutritional cause)& 
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
Link reference : https://amishajais1.blogspot.com/2022/03/16yrf-with-pancytopenia-fever-under.html

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