1801006109 LONG CASE


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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

A 23 year old female patient store manager by occupation r came to general medicine OPD with 


CHIEF COMPLAINTS 


• Pain in the left side of abdomen on and off since 1 year 




HISTORY OF PRESENTING ILLNESS 


• Patient was apparently asymptomatic 9 years back then she started developing pain in left hypochondrium which is insidious in onset intermittent & dragging type. since last one year she is having 1-2episodes of pain every month lasting for 30-60 min.


•c/o frequent onset of fever (once in 15-20 days) since 1 year, for which she visited a local hospital and found to be having low hemoglobin & started oral iron (used for one month) for which she had black coloured stools.


•c/o shortness of breath since one year ( Grade III MMRC)


•c/o early fatigability, tingling in upper and lower limbs 


•decreased appetite since 14 years of age 


•No H/o chest pain, pedal edema 


•No H/o orthopnea, PND 


•No H/o cold , cough 


•No bleeding manifestations 


•No c/o weight loss




PAST HISTORY


•Not a known case of  Hypertension , Diabetes mellitus , Tuberculosis , asthma , thyroid disorders, epilepsy , CVD , CAD 


• No H/o surgeries in the past 




FAMILY HISTORY


•No significant family history




PERSONAL HISTORY


• Diet - mixed 


• appetite - decreased


• sleep - adequate


• bowel and bladder - regular


• No addictions and no known allergies  




MENSTRUAL HISTORY 


• age of menarche - 12 yrs 


• Regular cycles , 3/28 , changes 3-4 pads per day. 


• No gynecological problems

GENERAL PHYSICAL EXAMINATION 


• patient is conscious, coherent, cooperative and well oriented to time, place and person.


• Thin built 


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

VITALS 



Temperature : afebrile


Pulse rate : 70 bpm


Blood pressure :110/70 mmHg


Respiratory rate : 18 cpm















SYSTEMIC EXAMINATION


PER ABDOMEN :


• inspection 


Shape - flat , no distention 


Umblicus - inverted, round scar around umblicus


No visible pulsations,peristalsis, dilated veins 


Visible swelling in the left hypochondrium , 6cm×4cm in size, oval shape, smooth, skin over swelling is normal 


Hernial orifices are free


• Palpation

No local rise of temperature and tenderness


 Spleen palpable ( moderate splenomegaly) 5cm below it's costal margin


 No palpable liver 


•Percussion


liver span -12 cm 


Spleen - dullness extending to left lumbar region 


Fluid thrill and shifting dullness absent


•Auscultation 

 

Bowel sounds present 



CARDIOVASCULAR SYSTEM:


•Inspection 


Shape of chest- elliptical shaped chest

No engorged veins, scars, visible pulsations

No JVP 


•Palpation 

 

Apex beat can be palpable in 5th inter costal space medial to mid clavicular line

No thrills and parasternal heaves can be felt


•Auscultation 


S1,S2 are heard

no murmurs

 



RESPIRATORY SYSTEM:


•Inspection


Shape of the chest : elliptical 


B/L symmetrical , 


Both sides moving equally with respiration 


No scars, sinuses, engorged veins, pulsations




•Palpation


Trachea - central


Expansion of chest is symmetrical.




•Auscultation


 B/L air entry present . Normal vesicular breath sounds

CNS:


•HIGHER MENTAL FUNCTIONS- 


Normal


Memory intact




•CRANIAL NERVES :Normal




•SENSORY EXAMINATION


Normal sensations felt in all dermatomes




•MOTOR EXAMINATION


Normal tone in upper and lower limb


Normal power in upper and lower limb


Normal gait




•REFLEXES


Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited




•CEREBELLAR FUNCTION


Normal function


No meningeal signs were elicited


Provisional diagnosis:-

Splenomegaly with anemia.



Complete blood picture

25/02/2023


HAEMOGLOBIN- 8.9 gm/dl
TOTAL COUNT - 2000 cells/cumm
pcv - 32.4
MCV - 78.6
MCHC - 27.5
RDW-CV 25.2
smear- microcytic hypochomic with leucopenia and thrombocytopenia

26/02/2023
HAEMOGLOBIN- 8.8 gm/dl
TOTAL COUNT - 2600 cells/cumm
pcv - 32.8
MCV - 79.0
MCHC - 26.8
RDW-CV 25.3 %
smear- microcytic hypochomic with leucopenia and thromobocytopenia

27/02/2023


HAEMOGLOBIN- 8.7 gm/dl
TOTAL COUNT - 2000 cells/cumm
pcv - 31.9
MCV - 78.6
MCHC - 27.3
RDW-CV 24.5
smear- microcytic hypochromic with leucopenia and thrombocytopenia

28/02/2023


HAEMOGLOBIN- 8.0 gm/dl
TOTAL COUNT - 1660 cells/cumm
lymphocytes -  41%
monocytes - 12%
pcv - 28.5 
MCV - 78.3
MCHC - 26.1
RDW-CV 24.6
smear- microcytic hypochromic with leucopenia and thrombocytopenia

1/03/2023



HAEMOGLOBIN- 8.9 gm/dl
TOTAL COUNT - 2000 cells/cumm
pcv - 32.4
MCV - 78.6
MCHC - 27.5
RDW-CV 25.2
smear- microcytic hypochromi with leucopenia and thrombocytopenia

2/03/203


HAEMOGLOBIN- 8.2 gm/dl
TOTAL COUNT - 1800 cells/cumm
lymphocytes - 41%
pcv - 29.3
MCV - 78.8
MCHC - 28.0
RDW-CV 24.6
smear- microcytic hypochromic with leucopenia and thrombocytopenia

4/03/2023



HAEMOGLOBIN- 8.7 gm/dl
TOTAL COUNT - 2130 cells/cumm
pcv - 30.0
MCV - 789     
MCHC - 28.6
RDW-CV 24.6
smear- Anisocytosis with normocytes microcytes tear drops pencil forms and macrocytes
impressions -Pancytopenia

7/03/2023



HAEMOGLOBIN- 9.2 gm/dl
TOTAL COUNT - 2000 cells/cumm
monocytes - 13%
pcv - 33.4
MCV - 82.1
MCHC - 27.5
RDW-CV 24.5
smear-  Anisocytosis with normocytes microcytes tear drops pencil forms and macrocytes
impressions -Pancytopenia

9/03/2023



HAEMOGLOBIN- 9.8 gm/dl
TOTAL COUNT - 2600 cells/cumm
pcv - 34.3
MCV - 80     
MCHC - 28.6
RDW-CV 24.5
smear-  Anisocytosis with normocytes microcytes tear drops pencil forms and macrocytes
impressions -Pancytopenia

12/03/2023



HAEMOGLOBIN- 8.8 gm/dl
TOTAL COUNT - 2000 cells/cumulative
lymphocytes - 42%
pcv - 30.1
MCV - 80.3
MCH - 23.5
MCHC - 29.5
RDW-CV 22.5
RBC 3.75 millions/cumm
smear-  Anisocytosis with normocytes microcytes tear drops pencil forms and macrocytes
impressions -Pancytopenia

13/03/2023

HAEMOGLOBIN- 8.7 gm/dl
TOTAL COUNT - 2000 cells/cumm
pcv - 29.8
MCV - 80.5
MCH - 23.5
MCHC - 29.5
RDW-CV 22.5
RBC - 2.70millipns /cum
smear-  Ansocytosis with normocytes microcytes tear drops pencil forms and macrocytes
impressions -Pancytopenia

APTT

Result- 41s
BLOOD UREA- 26 mg/dl
BLEEDING AND CLOOTING TIME

bleeding time - 2min
clotting time -4min

BLOOD GROUPING AND RH TYPE-B positive

PROTHROMBINE TIM- 2.0sec

SERUM CREATININE - 0.6 mg/dl


HIV - non reactive

Anti HCV antibodies -non reactive


ECG
USG
CT SCAN
Bone marrow biopsy 


Final Diagnosis : splenomegaly with pancytopenia


TREATMENT :-


 -inj. Taxim 1g OD


• inj. Pan 40g OD


• inj. Zofer OD


• tab livogen 150mg PO/OD


• tab ultracet 500mg PO/TID


• tab mvt PO/OD




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