A 17yr old female patient with jaundice
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A 17yr old female patient who is a student came to the OPD complaining about yellowish discolouration of eyes
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 6years back.
In 2016- Patient developed yellowish discolouration of eyes not associated fever or body pains.Then she took medication and it subsided after 15days
In 2017-Patient was diagnosed with asthma.She took medication about 1yr later it subsided
In 2018 and 2019 patient was normal without any complaints
In 2020-in May patient has menarch
In the month of august patient was diagnosed with jaundice and developed slight yellowish discolouration in the eyes.On medication it subsided
-In October-patient again diagnosed with jaundice and she was advised to visit hepatologist.
In 2021-February patient experienced decreased Hb%(3%) and visited KIMS.She was diagnosed with anemia underwent blood transfusion (2 bottles) and injection haemogram
In August-patient again developed decreased Hb% which dropped to about(<4%).She underwent blood transfusion with 20PRBC and in September with 10PRBC
In November 12th-patient developed yellowish discolouration of eyes.Vomtings 1episode daily for about 3days with food as content.Patient complaints of decreased apetite and weakness.
HISTORY OF PAST ILLNESS
Patient was a known case of asthma
No history of diabetes,hypertension,epilepsy and tuberculosis
PERSONAL HISTORY
Patient was poorly built
Decreased apetite
No sleep disturbances
Mixed diet
No history of deleterious habits
FAMILY HISTORY
There are no similar complaints in the family
GENERAL EXAMINATION
Patient was conscious,coherent and cooperative at the time of joining
Pallor present
Icterus present
No cyanosis
No clubbing
No lymphadenopathy
No pedal edema
VITALS
Temperature-98.6°F
Pulse rate-80beats/min
Respiration rate-20/min
BP-100/60 mm Hg
SYSTEMIC EXAMINATION
CVS
No thrills
S1,S2- +
No murmurs
RESPIRATORY SYSTEM
- Position of trachea is central
- Bilateral air entry is normal
- Normal vesicular breath sounds heard
- No added sounds
PER ABDOMEN
- abdomen is not tender
- bowel sounds heard
Spleen-moderate splenomegaly
CNS
- Patient is conscious
- Speech is present
- Reflexes are normal
INVESTIGATIONS
17-11-2021
Haemoglobin-5.8%
RBC-1.51million/mm3
TLC-12,300/microlitre
Platelet count-3.94/microlitre
18-11-2021
Hb-6.1%
RBC-1.56million/mm3
TLC-10,400/microlitre
Platelet count-2.34/microlitre
20-11-2021
Hb-7.15%
RBC-1.81million/mm3
TLC-7,100/microlitre
Platelet count-2.85/microlitre
LIVER FUNCTION TEST
19-11-2021
17-11-2021
TPR GRAPH SHEET
BLOOD SUGAR TEST
BLOOD UREA
SERUM CREATININE
SERUM ELECTROLYTES
LDH
USG REPORT
ECG
PROVISIONAL DIAGNOSIS
Acute haemolysis with jaundice
TREATMENT
Tab Prednisolone-20mg Po/OD
Tab Doxy 50mg PO/OD
Tab Folvite 5mg PO/OD
Tab Orofer PO/OD
Tab Shellal PO/OD
Cap Bio D3 PO/OD
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