26 year old male with pancytopenia and pyrexia


This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 



Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 




Cheif complaints : 

26 year old male presented with cheif complaints of fever since 1 week

Generalised weakness and headache since 1 week

Vomitings since 3 days

Loose stools since 3 days

History of presenting illness:

Patient was apparently asymptomatic 1week ago then he developed fever which is of high grade, intermittent type, associated with chills and rigor. Patient also mentioned that the rise in temperature will be atleast for 2hours in a day.

He went to orissa as the driver(dcm) in  while he developed fever then he returned to his home 2 days later.

He also had headache and generalised weakness since 1 week

Patient has fever with headache which is not associated with altered sensorium (meningitis -), not associated with photophobia, phonophobia(intra cranial injury -), diffuse headache (migrane -). 

He developed vomitings since 3 days, 5 episodes, with food as content, non bilious, non projectile, not blood stained

Loose stools since 3 days, 3 episodes/day, watery, green coloured, not blood stained.

He went to a doctor outside but the symptoms didnot subside, then he came here on 7/6/23




Past history :-

No H/o similar complaints in the past

Not a k/c/o DM, HTN, Thyroid disorders, epilepsy, asthma,Tb.

Personal history:- 

Diet:- mixed
Appetite:- normal
Bowel and bladder:- increased frequency
Sleep :- adequate 
Addiction:-
He takes alcohol 2 quarters from 6 years 

On examination:

Patient is conscious, coherent and cooperative 

No pallor, icterus,clubbing, cyanosis, lymphadenopathy, pedal edema 


Vitals:-

Temp- 99.5F

PR- 86 bpm

RR- 20 cpm

BP- 100/70mmHg

Spo2 - 99% on RA





RS-B/L air entry present 

       NVBS

CVS- S1S2 present, no murmurs heard

PA- Soft,non tender


CNS: NAD



Investigations :-

On 7/6/23

Hb: 14.9gm/dl

TLC: 900cells/cumm

RBC: 4.79 millions/cumm

PLATELETS: 50000 /cumm




Blood urea:52 mg/dl

Serum creatinine: 1.4 mg/dl



Serum Na+:139 mEq/L

Serum K+:4.0mEq/L

Serum Chloride:101 mEq/L



Bleeding time: 2min 30sec

Clotting time: 5min 00sec



PT: 20sec

INR: 1.4

APTT:41 sec




Stool for occult blood: Positive 



CUE

Albumin:+

Pus cells: 3-4/HPF

RBC: plenty



On 8/6/23

Hb: 13.3gm/dl

TLC: 900cells/cumm

Platelets: 50000 /cumm

RBC: 4.17million/cumm




Peripheral smear

RBC: Normocytic normochromic

WBC: counts decreased on smear

Platelet: counts decreased on smear






On 9/6/23

Hb: 12 gm/dl

TLC: 1300cells/cumm

RBC:3.78million/cumm

Platelets: 90,000/cumm

PCV: 35.4vol%



Serum creatinine:0.9mg/dl

Serum Na+ :139mEq/L

Serum K+: 4 mEq/L

Serum Chloride: 101mEq/L




APTT:43 Sec

PT: 22Sec

INR:1.62




Total Bilirubin: 4.93 mg/dl

Direct bilirubin: 3.46mg/dl

SGOT: 50 IU/L

SGPT: 18IU/L

Total proteins 5.0gm/dl

Albumin: 2.44gm/dl

A/G ratio: 0.95





On 10/6/23





Total Bilirubin: 2.37 mg/dl

Direct bilirubin: 1.99 mg/dl

SGOT: 79 IU/L

SGPT: 25 IU/L

Total proteins 4.5 gm/dl

Albumin: 1.69 gm/dl


A/G ratio: 0.58



Hb: 11.5 gm/dl

TLC: 1100 cells/cumm

RBC:3.63 million/cumm

Platelets: 62,000/cumm


PCV: 34.2 vol%



On 11/6/23



Total Bilirubin: 1.57 mg/dl

Direct bilirubin: 0.65 mg/dl

SGOT: 64 IU/L

SGPT: 30 IU/L

Total proteins 4.6 gm/dl

Albumin: 2.21 gm/dl


A/G ratio: 0.92



Hb: 11.3 gm/dl

TLC: 2000 cells/cumm

RBC: 3.58 million/cumm

Platelets: 70,000/cumm




PCV: 34 vol%



On 12/6/23



Hb: 11.6 gm/dl

TLC: 2400 cells/cumm

RBC: 3.66 million/cumm

Platelets: 80000/cumm





PCV: 35.2 vol%



Total Bilirubin: 1.17 mg/dl

Direct bilirubin: 0.23 mg/dl

SGOT: 62 IU/L

SGPT: 49 IU/L

Total proteins 6.2 gm/dl

Albumin: 3.3 gm/dl



A/G ratio: 1.74



Serum electrolytes 

Serum Na+ :140mEq/L

Serum K+: 4mEq/L


Serum Chloride: 100mEq/L

Differential diagnosis

Salmonella typhi?
 E. Coli?
Entameoba hystalytica?
malaria? 



Diagnosis:
Pyrexia with pancytopenia



Treatment:

1.IV FLUIDS NS, DNS, RL@ 125 ml/hr  

2.Tab.DOLO 650mg PO/TID

3.Inj.NEOMOL 1gm IV/SOS (if temp>102F)


4.Monitor vitals






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