case of anemia

18 year old girl presented to our opd at 9 15 am with the complaints of Irregular menstrual cycles since 2 years Fever since 20 daysDyspnea on exertion since 20 days Loss of appetite since 20 daysWeight loss over the last 20 daysFatigue since 20 daysCough - non productive since 10 daysFacial puffiness since 2 daysBilateral pedal edema since 2 days 
February 23, 2022
CBBLE UDHC SIMILAR CASES

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18 year old girl presented to our opd at 9 15 am with the complaints of 
Irregular menstrual cycles since 2 years 
Fever since 20 days
Dyspnea on exertion since 20 days 
Loss of appetite since 20 days
Weight loss over the last 20 days
Fatigue since 20 days
Cough - non productive since 10 days
Facial puffiness since 2 days
Bilateral pedal edema since 2 days 

18 year old girl, born out of a non consanguinous marriage. She is the eldest and she has 2 younger siblings, one currently in her 7th grade and the youngest in her 4th grade.  

She studied till 12th grade and is planning on joining a degree college. She attained her menarche when she was 15 years of age.

She complains of irregular menstrual cycles since the past 2 years - she gets her cycle once every 4 months and it last for 5 days, she complains of increased flow during these 5 days, she changes around 5 pads per day

Since 20 days she started to experience low grade fever, intermittent with no diurnal variation. She also started to feel dyspneic on walking short distances and would easily become tired. She also tells us that she lost her appetite gradually over the last 20 days, she stopped feeling hungry. Her parents tell us that she lost weight over the past 20 days, around 4 to 5 kgs.

She also complains of non productive cough since the past 10 days. 
Facial puffiness since 2 days 
Bilateral pedal edema extending upto her ankles since the past 2 days.

She however gives no history of consuming any bleeding manifestations, drugs, herbal medications, 

On examination:

She is a thin built girl with
Pallor +
Facial puffiness +
Pitting type of pedal edema extending upto her ankles +
PR - 115bpm
BP- 100/50mmhg
RR - 20 cpm
Afebrile
Grbs - 100mg/dl
Weight 22 kgs
Height - 147cms

JVP - raised
https://youtube.com/shorts/lUn1NIvz33E?feature=share

Apical Pulse Video link - 
https://youtu.be/JuR86moaVts
Parents H/o
Both of her parents used to work as daily wage laborers but since the past 5 to 6 years her mother stopped working and stays at home taking case of household chores and her children.
Her father opened a small shop for electrical supplies 
He gets around 6000 to 7000 from this
Apart from this they get rent from one of their properties which is around 5000

So they get around 12000 to 15000 per month sir

And when asked if it is sufficient for them to provide food for all the 5 members of the family, she says sometimes it isn't that's when they borrow money or arrange food with the help of others

INVESTIGATIONS

Pretransfusion Hb - 1.7gm/dl
Blood Transfusion Done On
23/02/2022 - Hb After Transfusion - 4.3 gm/dl
24/02/2022 - Hb after Transfusion - 7.5 gm/dl

RFT on 23/02/2022

Na+ - 136
k+ - 3.5
cl - 105
S.Creat - 0.4
Uric Acid - 1.5
Urea - 13

LFT on 23/02/2022

Total Bilirubin - 0.74
Direct Bilirubin - 0.20
Ast - 25
ALT - 10
Alk Phosphate - 163
Total Protein - 6.5
Alb - 3.5
A/G - 1.2

HAEMOGRAM on 23/02/2/2022

Haemoglobin - 1.7gm/dl
TC      - 1900
Pcv     - 6.7
RBC     -  1.72lakh
Platelets - 36,000

HAEMOGRAM on 24/02/2022

Haemoglobin - 7.5 gm/dl
TC      - 4800
Pcv    - 23.7
MCV  - 86.5
RBC   - 2.74 
Platelets - 30,000

HAEMOGRAM on 25/02/2022

Haemoglobin - 7.5gm/dl
TC - 1600
Pcv - 6.7
RBC - 0.88
Platelets - 45,000

Stool For Occult Blood - Negative


SEROLOGY - Negative
Malaria MP Strip - Negative
Dengue NS1 , IG - Negative


Blood Group - O Positive
Bleeding Time - 2 mins
Clotting Time - 5 mins
Aptt - 33 Sec
Pt - 17 sec
INR - 1.2


Her peripheral smear showing Microycytic hypochromic picture with tear drop cells, pencil forms, Anisopoikilocytosis
Her retic count is 0.8

LDH - 248 
ESR - 140

2D Echo :
* EF - 60 %
* Trivial Tr + / Ar +
* No RWMA , No As/ Ms , No PAH PE
* Good LV Systolic Function
* no Diastolic Dysfunction 

USG Abdomen Impression :-
* No Sonological Abnormality 

ECG 

Treatment Given 

1) Dolo 650mg Po / Sos
2) Inj Optineuron 1 Amp in 100ml NS / IV / OD
3) Inj Monocef 1gm IV / BD
4) One Unit Of Blood Transfusion Done On 23/02/2022 

       
             SOAP NOTES DAY 2
S : 
Fever 
Cough decreased
Dyspnea on exertion Subsided
Facial puffiness Subsided
Bilateral pedal edema Subsisded


O - Patient is conscious,coherent,cooperative
 PALLOR +  

Pretransfusion Hb - 1.7gm/dl
Blood Transfusion Done On
23/02/2022 - Hb After Transfusion - 4.3 gm/dl
24/02/2022 - Hb after Transfusion - 7.5 gm/dl

vitals :

temp- afebrile
BP -100/70 mm hg 
PR - 100 bpm. 
RR - 19 cpm 
spo2 100 @RA 
GRBS -122 mg/dl @ 7 am
CVS - S1, S2 heard 
RS. :- bae present 
P/A: soft, non tender 
CNS :- NAD


A:- Panconytopenia ( Dimorphic Picture Secondary To ? Nutrional Anaemia )

P:
1) One Unit PRBC transfusion Done on 24/02/22.
2) Inj Optineuron 1 amp in 100 ml NS0 OD
3) Inj Vitcofol C 1500mcg IV / OD in 100 ml NS
4) Inj Iron Sucrose 100 mg in 100 Ml NS
5) Tab Dolo 650 PO / SOS





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