ANAEMIA?
24 yr old male came with c/o fever since 1 week on and off subsided on taking medication associated with dry cough since 1 week, no c/o cold , vomitings, loose stools
Soap notes day 2
He was apparently assymptomatic 1 year back then he developed fever and yellowish discolouration of eyes for which he took herbal medication and was subsided .
6 months back post festival he again developed yellowish discolouration of eyes and was told red blood cells were low and was administered iron supplements.
He complaints of intermittent fever since yr which subsides on medication
At present he c/o fever since 1 week
Denies h/o Malena ,hemoptysis ,hematemesis and recent blood transfusion
He had delayed milestones,delayed walking and talking compared to his elder brothers.
BIRTH HISTORY- born of 3 rd degree consanguinous marriage ,normal vaginal delivery ,wasn't breast fed ,had buffalo milk
Not a K/C/O DM,HTN, asthma , epilepsy,TB.
PERSONAL HISTORY:- patient is Vegetarian,with good appetite and adequate sleep , has constipation
No significant family history
GENERAL EXAMNATION
Patient is c/c/c.
No pallor, cyanosis, clubbing, lymphadenopathy, pedel edema.
Vitals
temp: 97 F
PR: 92bpm
RR: 18 cpm.
BP: 100/60 mmhg.
SPO2: 98% at RA.
RS: BAE +, NVBS
CVS: S1 ans S2 heard. No murmurs.
P/A: soft and non-tender.
CNS: No focal deformities.
INVESTIGATIONS
Hemogram:-
Hb-5.5 g%
Tlc- 3500 cells /cumm
N/L/M/E- 62/32/5/1
Plt- 1.5 lakhs/cumm
RBC count-1.93 million /cumm
MCV-84.2
MCH-28.7
MCHC-34.1
RETICULOCYTE COUNT- 0.7%
Peripheral Smear-
RBC- anisopoikilocytosis with hypochromia with minocytes ,manocytes,manoovalocytes ,fee pencil forms
WBC- reduced on smear
Platelets- adequate
impression- dimorphic anaemia with leucopenia
CUE- normal
Smear for malarial parasite - negative
PROVISIONAL DIAGNOSIS
Viral pyrexia with dimorphic Anaemia under evaluation
SOAP notes day 1
22/10/21
S: no present complaints
O:Pt is conscious, coherent and cooperative
O/E
PR :78 BPM
BP : 110/70 mmHg
RR : 20cpm
Temp:98.2F
CVS: S1,S2 heard
RS: NVBS +
P/A-Soft non tender, Bowel sounds+
CNS: NFD
A: viral pyrexia with thrombocytopenia with anemia under evaluation
P:
1)Inj Neomol 1gm IV SoS
2) Tab Dolo 650 mg po SOS
3)Tab Orofer 50 mg po bd
4) Syp.Ascoril D 10 ml po bd
5) Syp.cremaffin 10 ml po sos
6) inform SOS
Investigations:-
Serum iron- 100 micro gm /dl
Serum ferritin- 280.2 ng/dl
RBS- 89mg/dl
Thyroid profile-
T3- 1.04 ng/dl
T4- 12.37 micro gm/dl
TSH- 0.71micro lu/ml
Direct coombs test - negative
Indirect coombs test- negative
S: no present complaints
O:Pt is conscious, coherent and cooperative
O/E
PR :76 BPM
BP : 120/70 mmHg
RR : 21cpm
Temp:98.2F
CVS: S1,S2 heard
RS: NVBS +
P/A
Soft non tender
Bowel sounds+
CNS: NFD
A: viral pyrexia with thrombocytopenia with anemia under evaluation
P:
1)Inj Neomol 1gm IV SoS
2) Tab Dolo 650 mg po SOS
3)Tab Orofer 50 mg po bd
4) Syp.Ascoril D 10 ml po bd
5) Syp.cremaffin 10 ml po sos
6) inform SOS
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