18 yr old female with pancytopenia
24 February, 2022
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Khushi Tulsyan
Roll no. 75
A 18 yr old female patient presented to opd for blood transfusion.
HISTORY OF PRESENTING ILLNESS-
Patient was apparently asymptomatic 40 days back.She had her 1st dose of vaccination (covishield/covaxin not known) then she developed mild fever pain at the site of injection and was doing well until 20 days back where she had her periods (regularly irregular - once in two months ) she was lethargic it is known to be having it everytime since she gets her periods there was no change in her fever and pain and she had dyspnea on exertion and was shown to local doctor where her blood levels were checked and found to be low ( not known by attender) and a tonic (zincovite) was given to her. She showed no signs of improvement and started having shortness of breath grade 4 and was shown to the some other hospital 2 days back. There she was give some tonic(ferric oxide) for increasing her blood she was found to be low and blood transfusion was advised. She presented to our hospital for blood transfusion.
No known recent infection/trauma/medication.
PAST HISTORY-
Not a known case of htn/dm/ aasthma/leprosy/epilepsy.
MENSTRUAl HISTORY-
Menarche - 16 yrs
Has an cycle of once every 2-3 months
2-3 pads/day lasting for 5 days.
PERSONAL HISTORY-
Diet - Vegeterian- (had vomiting when young on ingestion of chicken - so doesn't consume)
Appetite- decreased since vaccination
Bladder and bowel - regular
Addictions - none
Allergy - not known
Decreased weight according to age - 22kgs.
FAMILY HISTORY-
No known family history.
Has 2 younger siblings ( sisters) who are thin according to age according to the mother.
But they have non veg.
GENERAL EXAMINATION-
Patient is examined under well lit room and adequate ventilation with his consent taken
Patient is conscious , coherent and cooperative well orientated to time, space and person. He is moderately built and nourished.
Pallor is present.
No icterus, edema, lymphadenopathy, clubbing, Cyanosis.
VITALS-
Temp - afebrile
BP - 110/70
Pulse - 110 bpm
Resp rate - 15 cpm
Sp O2 - 97 %
SYSTEMIC EXAMINATION-
CVS -
S1, S2 heard
On palpation :
Parasternal heeves heard
Apex beat heard
Raised jvp
ABDOMEN-
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