35 yr old pt with pancytopenia
Chief complaints:
C/o of vomitings since 3 days
C/o pain abdomen since yesterday morning
History of present illness:
Patient was apparently asymptomatic 3days ,back,then developed vomitings since 3 days,5-6episodes per day,content being whatever she ate and drank,yellowish in colour,non projectile,non foul smelling.
Pain abdomen since yesterday,at the umbilicus,sudden in onset,not progressive,not radiating, pain aggravated after vomiting episode,relieved with medication.
H/O nausea is present
No H/O constipation, diarrhoea,
burning micturition is present
H/O 1 episode of black stools yesterday
Past history:
Patient is not a k/c/o htn , dm , asthma, epilepsy, thyroid disease
H/O blood transfusion 15 yrs back
Diet :mixed
appetite: normal
Bladder and bowel :normal .
Sleep:adequate.
addictions: none
vitals:
temp:afebrile
BP:130/70 mm of hg
PR:72bpm
RR:18cpm
General examination :
pt is conscious,coherent and cooperative
pallor present
No icterus
cyanosis,clubbing,edema or lymphadenopathy
systemic examination:
P/A:non tender
No organomegaly
Respiratory system
bae +
No wheeze, crepitations
Cvs :s1 s2 heard,no murmurs
Cns: no focal neurological deficit seen
Provisional diagnosis:
Pancytopenia under evaluation
Treatment:
Day 1:
Inj pan 40 mg IV/bd
Inj zofer 4 mg IV/TID
Inj optineuron in 100 ml NS/iv/TID
Ivf-10 NS,10 RL @50 ml/hr
Day 2:
Inj pan 40 mg IV/bd
Inj zofer 4 mg IV/TID
Inj optineuron in 100 ml NS/iv/TID
Ivf-10 NS,10 RL @50 ml/hr
Inj vitcofall IM/OD
Tab.sporlac po/TID
Tab.hifenac p 300mg/po/bd
Day3:
Inj pan 40 mg IV/bd
Inj zofer 4 mg IV/TID
Inj optineuron in 100 ml NS/iv/TID
Ivf-10 NS,10 RL @50 ml/hr
Inj vitcofall IM/OD
Tab.sporlac po/TID
Tab.hifenac p 300mg/po/bd
Day4:
Inj pan 40 mg IV/bd
Inj zofer 4 mg IV/TID
Inj optineuron in 100 ml NS/iv/TID
Ivf-10 NS,10 RL @50 ml/hr
Inj vitcofall IM/OD
Tab.sporlac po/TID
Tab.hifenac p 300mg/po/bd
Investigations:day 1
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