17yr old Female presented with yellowish discolouration of Eyes

 

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Name - S.Kavya, 9th sem

Roll no - 121

I have been given this case to solve an attempt to understand the topic of "patient clinical analysis data " to develop my competency in reading and comprehending clinical data including clinical history,clinical findings, investigations and come up with a diagnosis and treatment plan

17 year old female who is the first child of a consanguinous married couple

She has 2 younger brothers who are apparently alright with no health related issues

Since childhood she has been having recurrent Respiratory tract infections(She almost always had cold,fever,cough with sputum) aggravated during winters

4years back(2016) she had h/o jaundice and anemia for which one blood transfusion was done,her jaundice subsided slowly .

Since 4yrs she is complaining of yellowish discoloration of eyes on and off not preceeded by fever with no h/o pruritus,No history s/o CLD

She gives h/o easy fatigability , generalized weakness since 4years 

h/o short stature,failure to gain weight appropriate for her age and delay in secondary sexual characters

Attained menarche in 2020 May had regular cycles of 4months and then  2months of ammenohrea,2months of regular cycle and then followed by amenorrhea till now.

In October 2020she again developed yellowish discoloration of eyes which subsided on its own

2021 jan yellowish discoloration of eyes recurred and not subsided 

h/o 2 blood transfusions in feb 2021

No proper immunization history or documents available.

Evaluated in various hospitals since childhood

On 18th Nov 2021 , she presented to casualty with complaints of yellowish discoloration of eyes since 5 days 

associated with dark coloured urine  

no h/o fever ,abdominal pain

c/o vomitings since 3 days, 3 episodes,food as the content,non projectile 

c/o mosquito bites 2 days ago followed by rashes on B/L limbs

in August 2021- 2 pint PRBS transfusion done

in September 2021- 1 pint PRBS transfusion done

previous h/o 4 blood transfusions

personal history

appetite -normal

bowel movement- regular

micturition - normal

no known allergies

no addictions

family history

Insignificant

general examination

pallor+

icterus+

no cyanosis,clubbing, lymphadenopathy and edema

temp-98.6F.

pulse: 80bpm

respiration: 20 bpm

BP - 100/60 mmHg

spo2 - 99%

CVS:

s1,s2 heard

RS:

BAE +,NVBS heard

Abdomen

soft,non tender , moderate splenomegaly

CNS 

NAD

provisional diagnosis

Common variable  immunodeficiency syndrome ? with auto immune hemolytic anemia with acute  hemolytic episode

Treatment

1) Tab. Predinisolone 20 mg po/OD

2) Tab.Azathioprine 50 mg po/OD

3) Tab.Doxycycline 50 mg po /BD

4) Tab.Folvite 5 mg po/OD

5) Tab .Orofer -XT po/OD

In detail Previous history during her last admission and her previous medical conditions (since birth) can be found in the case report link attached below -

https://chandanavishwanatham19.blogspot.com/2021/03/17year-old-female-with-recurrent.html?m=1