e log



15 yr old woman, in her intermediate second year, whose father is a farmer and mother is a daily laborer and has 2 elder siblings (elder sister who is in B tech first yr and twin brother passed his inter 1st yr) residing at Duppali, Nalgonda district presented to the opd with the chief complains of
Generalised weakness since 1 month 
Loss of appetite since 1 month 
Headache since 1 month
Yellowish discoloration of sclera and  urine since 1 week
Vomitings since 3 days 
She attained menarche 6 months back since then she has been having regular cycles, 2 pads per day, 5/30, she skipped her cycle last month otherwise her cycles have been regular. 
She was apparently alright 4 years back when she started feeling weak, found it difficult to participate in sports, her parents even observed she was getting pale then she was taken
to a local hospital where she was told that  she had anemia and was given medications. She was not given any blood transfusions. 
She continued with normal daily activity and gave no complains of weakness until 1 month back. 
Since 1 month she again started experiencing generalized weakness, loss of appetite and diffuse throbbing type of headache.
1 week back her parents observed that her eyes were yellow in color for which she took herbal medications for 1 week aft
er which she had 
vomitings which were green in color, non projectile, aggravated on intake of food, which lasted for 2 days, around 3 episodes per day 
She gives no complains of dark colored stools, red colored urine 
No complains of fever, night sweats, weight loss, diarrhea
No history of drug intake such as cephosporins, penicillins, NSAID use
No family history of hemolytic anemia
No history of any blood transfusions 
On examination patient appears pale, thin built
Pallor - present 
Icterus - present 
With a BP of 110/70
PR 80bpm
Afebrile 
Cvs - 
Palpable thrill present
On Auscultation - flow murmur present 
 Respiratory : bilateral air entry is present 
Lungs - clear on auscultation 
Per abdomen :
Inspection : abdomen is normal with no scars and sinuses 
No visible pulsations 
On palpation of her abdomen, temperature is afebrile. There is diffuse tenderness
Spleen is palpable 3cm from the costal margin of anterior axillary line
LFT
RFT
HEMOGRAM


SERUM IRON
MP test 
PT
APTT
Peripheral smear 
XRay of chest and erect abdomen 

ULTRA SOUND

2DECHO
ECG
Abg
Peripheral smear 
Probable diagnosis :pancytopenia, anemia with secondary to vitamin b12 deficiency and iron deficiency 
Treatment at the hospital :

1.inj.pan 40 mg Iv od

2.inj.zofer 4mg Iv sos

3.inj.optineuron 1amp in 100ml NS Iv od

4.syp.Aristozyme 10ml PO BD

5.adequate oral fluids

6.T.folic acid 5 mg od

7.T.pan 40mg od

8.T.orofer -xt bd

9.T.neurobion forte od



Advice at discharge 

 1.Syp.Aristozyme 10ml po bd

 2. T.folic acid 5mg od

3.T.pan 40mg od

4.T.orofer -xt bd







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