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 3 days
History of presenting illness:
Currently ,in 2023:
She was apparently asymptomatic 5 days back then she developed pain in left ankle initially which progressed and since 3 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 ,redness
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:
She is second born child of parents married of 3rd degree consanguinity in 2009.
All trimesters were uneventful.
She was delivered through Caeserean section because of delayed labour pain with birth weight of 3kg.
PAST HISTORY -
2012
She was asymptomatic till age of 3
Then she developed high grade fever ,cough and vomiting
Diagnosed with sickle cell Anemia
Sickling test positive
Electrophoresis shows hbs
Blood transfusion given 1 packet
2013
She developed highgrade fever,cough and cold
Then she was diagnosed with bronchopneumonia
2015
Recurrent episodes of fever cold and cough
(6 episodes in 3 years )
2016
She developed fever, abdomen pain, arthralgia and myalgia
Improved on medication and discharged
2019
Stomach pain and vomiting
Diagnosed with ACUTE PANCREATITIS
2022
Stomach pain
-sudden in onset , gradually progressive, pricking type in epigastrium and left hypochondrium andVomitings
Dark coloured stools and dark urine
Pain in both lower limbs (muscle pain more on right than left) and lower back pain since 3 days.
K/C/O OF sickle cell anaemia since 2012
H/O 8 PICU admissions
history of recurrent Bronchopneumonia ,
History of sickle cell crisis in 2016
History of pancreatitis in 2019
H/O blood transfusions - done about 20 times till now and last transfusion was done in January 2023
No H/O of asthma,thyroid,Tuberculosis, Hypertension, Diabetes,Epilepsy
No h/o of bone pain with localized swelling
IMMUNIZATION HISTORY
patient is immunised till date
Pneumocccal,typhoid,hepatitis vaccine taken on 23/1/22
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 absent
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- flat. Umbilicus everted. No scars. No organomegaly. Bowel sounds heard.
CVS- S1 S2 heard, no murmurs
apex beat shifted downwards laterally
RS- NVBS.
CNS- No focal neurological deficits
Tone, power and reflexes are normal.
On examination on lower limbs bilateral calf tenderness is seen.
Provisional Diagnosis: Anemia
Clinical pictures:
X-rays:
INVESTIGATIONS
Hemoglobin-8gm/dl
TLC-22,900
PCV-23.1(normal-36 to 46)
BLOOD group -O positive
Total bilirubin
Direct bilirubin
SGOT-170
SGPT-180
ALP-560
CRP-negative
Serology -negative
blood urea-20mg/dl
Peripheral smear-
Anisopoikilocytosis with predominant Sickle cell,normocytes,few microcytes
Platelets and wbc were raised
Diagnosis :sickle cell anemia with vaso occlusive crisis
CURRENT MANAGEMENT ( mainly pain management)
IVF NS and DNS
Inj PAN 40 mg/day
Inj OPTINUERON
inj DICLO
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