1801006163 Short Case

 1801006163 SHORT CASE

March 2023

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

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.

Patient and his/her attenders have been informed and their consent has been taken.




A 14 year old female , resident of nagarjun sagar came to opd with  chief complaint  of pain in both the lower limb since 7days

HISTORY OF PRESENT ILLNESS 

She is second born child of parents married of 3rd degree consanguinity in 2009. All trimesters were uneventful. She was delivered through Cesarean section because of delayed labour pain with birth weight of 3kg.

Immunized till date.

2012

She was asymtomatic upto age of 3 years, then she developed high grade fever with cough and vomitting. She was diagnosed with Sickle cell anaemia. Sickling test positive and Electrophoresis showed HbS. Blood transfusion were given 1packet.

2013

She developed high grade fever, dry cough and cold. She was diagnosed with Bronchopneumonia. X-ray lower lobe consolidation.

2015

She had recurrent episodes of fever, cough , cold i.e Recurrent Bronchopneumonia- 6 episodes in 3years. Urine culture showed Klebsiella growth.

Blood transfusion till date 4 times.

2016

She developed fever, pain abdomen , myalgia and arthralgia. She improved on medications and thus was discharged.

2019

She came with stomach pain and vomitting. She was diagnosed with Acute pancreatitis.

2023 Jan 

Blood Transfusion done
Diagnosed to have cholelithiasis

2023 March

She was apparently asymptomatic  7 days back then she developed pain in left ankle for which she took TAB.ULTRACET  and since 4day she developed pain in both knee and then she developed tenderness in the calf muscles it is of throbbing type in nature 
She complaints of right lower leg pain from knee to ankle, dragging type, continuous, not relieved on medication associated with swelling below right knee over shin of tibia
She has fever 
All the peripheral pulses are palpable

No history of chest pain,shortness of breath,palpitations.
No history epigastric pain, vomitting
No history of headache, seizures,altered mental status








PAST HISTORY 

She is a known case of sickle cell anemia
 History of bronchopnemonia
 History of 8 PICU admissions 
 History of blood transfusion (20 times till now) last transfusion was done in jan 2023
No History of asthama,thyroid,Tuberculosis, Hypertension, Diabetes,Epilepsy
No history of bone pain with localized swelling in past
No history of any surgery. 

PERSONAL HISTORY 

Diet-mixed
Appetite-normal
Sleep-adequate
Bowel and bladder movements are regular
No allergies
No addictions 
Not aattained menarche

FAMILY HISTORY 

3rd degree consanguinious marriage

No known affected relatives

PEDIGREE CHART




IMMUNIZATION HISTORY 

patient is vaccinated according to national immunization schedule
Pneumocccal,typhoid,hepatitis vaccine taken on 23/1/22



GENERAL EXAMINATION 

Patient was conscious, coherent and cooperative. Well oriented to time, place and person.

Pallor present




Icterus present 
       Right eye


       Left eye

Local edema on shin of right tibia



 No Cyanosis, clubbing, lymphadenopathy


Vitals

Temp: Afebrile 

PR- 96 bpm  

RR- 18/Min

Bp-110/70mm of hg

Spo2-99%

BP- 110/70 mmHg

Height-144cm

Weight- 36kg

Fever chart



SYSTEMIC EXAMINATION 
 
Per Abdomen - Soft , tender over left hypochondriac. No organomegaly

CVS- S1 and S2 heard ,no murmurs 

RS- Bilateral air entry present,normal vesicular breath sounds are heard

CNS-no neurological deficit 


PROVISIONAL DIAGNOSIS 
Sickle cell anemia with vaso occlusive crisis

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-sodiun- 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




WBC count increased
Platelet  count increased
 
X-RAY 











Treatment History
IV  FLUID IONS @75ml/kg
TAB PENICILLIN 800mg PO 
TAB FOLIC ACID 5mg PO OD
TAB ECOSPIRIN 75 mg PO OD 
TAB HYDROXYUREA 1000mg PO OD
TAB TRAMADOL 1Ampoule in 100 ml NS SOS
TAB PANTOP 40 mg IV OD
TAB SHELCAL 500mg PO OD
TAB ZOFER 4mg IV SOS
TAB NAPROXEN 250 mg PO BD

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