1801006109 Short case

 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". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 

I've 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 a diagnosis and treatment plan.





Cheif complaints:


A 14 year old female,resident of nagarjuna sagar presented with cheif complaints of 

Pain in lower limbs (more in right knee) and lower back pain since 6 days 





History of presenting illness:-


She was apparently asymptomatic  6days back then she developed pain in left ankle initially which is progressive and since 1 day she developed pain in both knee (more on the right side>>left) which is of throbbing type in nature . 

Tenderness in calf muscles is present.

No aggravating and relieving factors

No history of fever ,abdominal pain



No H/o of swelling, weakness.


All the peripheral pulses are palpable


No h/o chest pain,shortness of breath,headache and palpitations 


No h/o aphasia or dysphagia, seizures,Severe headache,altered mental status


BIRTH HISTORY:


Second child 

Consanguineous 3 rd degree 

 All trimesters were uneventful. 

-She was delivered through Caeserean section

-Birth weight of 3kg.

PAST HISTORY - 

At the age of 3 she had complaints of fever,sob,fatigue, patient was diagnosed as sickle cell anemia since then She underwent multiple PRBC transfusion 20times in 11years last PRBC transfusion was in jan 2023.

H/O similar Complaints in the past for 3 times.

H/O jaundice 2yrs ago

H/O cholelithiasis 3months ago 

Not a Known case of DM,HTN,CAD,CVA, EPILEPSY

IMMUNIZATION HISTORY 

BCG scar present.

patient is immunised till date



PERSONAL HISTORY :


Diet: mixed

Appetite: normal

Sleep: adequate

Bowel and bladder movements regular

No addictions


FAMILY HISTORY - 


3rd degree consanguity of parents

No known affected relatives

GENERAL EXAMINATION:


Patient was conscious, coherent and cooperative. 

Well oriented to time, place and person.

Moderately built and nourished.


Pallor present


Icterus present 


Cyanosis, clubbing, lymphadenopathy, Pedal edema absent


Vitals


Temp: Afebrile 


PR- 96bpm    


RR- 18/Min


BP- 110/70 mmHg


SYSTEMIC EXAMINATION


P/A - Shape of abdomen- Normal. Umbilicus everted. No scars. No organomegaly. Bowel sounds heard.


CVS examination -

-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


•Auscultation 


S1,S2 are heard

no murmurs

RS- NVBS.


CNS- No focal neurological deficits


Tone, power and reflexes are normal.


On examination on lower limbs bilateral calf tenderness is seen.



Clinical pictures:










Peripheral smear


X ray







Provisional diagnosis:-

Hemolytic Anaemia ?


INVESTIGATIONS :-


Hemoglobin-8gm/dl

TLC-22,900

PCV-23.1(normal-36 to 46)

BLOOD group -O positive 

Total bilirubin-20.15

Direct bilirubin-14.13

SGOT-170

SGPT-180

ALP-560

CRP-negative

Serology -negative

LDH-

blood urea-20mg/dl


Creatinine-0.4

Electrtrolytes-

sodium- 136 mEq/l

Pottasium-4.5 mEq/l

Chloride-101mEq/l

Calcium 1.02mmol/l


Peripheral smear-


  Anisopoikilocytosis with predominant Sickle cell, normocytes, few microcytes

Platelets and wbc were raised 







Final diagnosis:-

Sickle cell anaemia with vaso occlusive crisis.

Treatment:-

IV FLUID IONS@75ml/hr

TAB.FOLIC ACID 5mg PO OD

TAB.ECOSPRIN 75mg PO OD

TAB.HYDROXY UREA 1000 PO OD

INJ.TRAMADOL 1Amp in 100ml NS SOS

INJ.PANTOP 40mg IV OD

INJ.ZOFER 4mg IV SOS

TAB.NAPROXEN 250mg PO BD




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Read more