1801006098 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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.

14yr old female  from Nalgonda has presented with complaints of pain in both knees since 3 days.

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 6 days ago then she developed pain in left ankle  which was progressive and relieved on taking pain killer  and  since 3 days she developed pain in both knees  there is no swelling.

No history of redness

No h/o weakness

No h/o chest pain,palpitations

No H/O shortness of breath,headache 

PAST ILLNESS:              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

PERSONAL HISTORY:

Appetite is normal

Mixed diet

Regular bowls

Normal micturation 

Known dust allergies 

FAMILY HISTORY:

No relavent family history 

GENERAL  EXAMINATION:

Patient is Consious ,coherent well oriented to time place andnperson

pallor is present

No icterus, cyanosis, clubbing, generalized lymphadenopathy, edema

Vitals:

Temp:97.5F

PR:62bpm

BP:130/80mm/hg

RR:18cpm

SPO2:96%at RA

GRBS:134mg%

Examination-

Cvs-

Inspection- chest appears normal,symmetrical,no visible sinuses,dilated veins,scars,no visible pulsations

Palpation-apical beat shifted downwards laterally

Auscultation -s1,s2 heard

P/A -

Inspection-abdomen flat,no scars and visible peristalsis

Palpation- no organomegaly

auscultation-bowel sounds heard

Respiratory system-normal vesicular sounds heard ,no added sounds

Cns- higher mental functions intact

Tone ,reflex,power normal.

Provisional diagnosis-anemia

INVESTIGATIONS-

Peripheral smear-

  RBC- anisopoikilocytosis with predominant sickle cells,normocytes and few microcytes

WBC- increased count on smear

Platelets-increased count on smear

Impression- sickle cell anemia with leucocytosis and thrombocytosis.

Complete blood picture- 

Hb-8gm/dl

Total count-22000cells/cu mm

Neutrophils-79%

Eosinophils-0%

Lymphocytes-18%

PCV-23.1%

MCV-98.3fl

MCH-34pg

MCHC-34.6%

RDW-CV-21.9%

Rbc count-2.35 millions/cu mm

DIAGNOSIS:

Vaso occlusive crises secondary to Sickle cell anemia.

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