12 yr old female with Anemia

 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-centered online learning portfolio and your valuable inputs on the comment box.

CHIEF COMPLAINTS 

12 yr old female patient came to the opd with chief complaints of
1)Fever( low grade) 5days back.
2)Cough associated with sputum since 3days.

HISTORY OF PRESENTING ILLNESS 

Patient was Apparently asymptomatic 7 days back then she had low-grade fever which is intermittent in nature (temperature used to rise in night) for 2 days which is associated with body pains and not associated with chills and rigor. She went to a private hospital and found to have low hemoglobin& low platelet count .Then after 5 days patient had cough associated with sputum which is non blood stained.

PAST HISTORY

No similar complaints in the past .
Not a known case of DM,HTN,TB,ASTHMA, EPILEPSY.

PERSONAL HISTORY

Moderately built and nourished.
Sleep adequate.
Appetite normal.
Bowel and bladder are regular.
No addictions.

GENERAL EXAMINATION

Patient was conscious coherent cooperative 
Pallor - present 
No ICTERUS , cyanosis,clubbing,generalized lymphadenopathy, pedal edema.
VITALS
Temp -Afebrile.
PR-77bpm
RR-24 cpm
Bp-90/70 mm hg

SYSTEMIC EXAMINATION 

•CVS : S1 and S2 heart sounds heard .No murmurs and thrills.
•RESPIRATORY SYSTEM : Bilateral air entry present. 
position of trachea - central.
Vesicular breath sounds                                                heard.
•CNS : NAD
•ABDOMEN : Soft and non tender
              No palpable masses
              Bowel sounds heard 
              Mild splenomegaly and mild hepatomegaly is present.





FEVER CHART



INVESTIGATIONS









DIAGNOSIS:-
SEVERE ANEMIA UNDER EVALUATION

TREATMENT:-
INJ.OPTINEURON in 100ml NS over 30 mins.IV/OD.

SOAP notes 28/08/2022

12 year old female

S: Fever spikes subsided

O: Pt is conscious andcoherent
PR:70bpm
RR: 14cpm
BP: 110/70 mmHg
Temp: 96.9F
CVS: S1,S2+,No added
sounds
R/S: BAE+,clear
P/A: soft and non tender CNS: NAD

A:-Anemia under evaluation 

P:INJ OPTINEURON IN 100ML NS OVER 30MINS IV/OD.

SOAP notes 29/08/2022

S:Fever spikes subsided

0: Pt is conscious and
coherent
PR:70bpm
RR: 14cpm BP: 110/70 mmHg
Temp: 96.9F
Spo2:- 100%
CVS: S1,S2+,No added
sounds
R/S: BAE +,clear
P/A: soft and non tender
CNS: NAD

A:-Anemia under evaluation

P:
1 blood transfusion was done on 29/08/2022
Inj. Iron sucrose 200mg/ivin 100ml NS slow over
Sup. Ascoryl 10mlPO/BD
Tab. orofer XT  PO/OD
INJ OPTINEURON IN 100ML NS OVER 30MINS IV/OD.







Comments

Post a Comment

Popular posts from this blog

48 yr male with ascites, pedal edema since 2 months

Image
  This is an a 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 The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 
Read more

Internship learning and procedures performed

Image
 INTERNSHIP LEARNING AND PROCEDURES PERFORMED This is prathyusha posted in medicine department from October 1st to 30 th November.   From 1st of oct to 15th October I was posted in peripherals Icu, nephro, ward In icu-  During my icu, amc duties  -I monitored vitals of patients every hourly -Took abg samples -put ryles tube for feeding -foleys catheterization - Done CPR in the icu - blood transfusion  In nephrology postings : Assisted in central line procedure and done suturing Monitored patients undergoing dialysis  Learnt about dialysis procedure In ward - took blood samples, monitored vitals  I was posted in psychiatry from 16th to 30th October In the OP saw cases of schizophrenia, Alcohol dependence syndrome, obsessive compulsive disorder.  Used to monitor patients in the De addiction center. One of the admission during my posting  Diagnosis - panic attack A 19 yr old male came to op with chief complaints of Increase in heart rate, hearing his own heart beat, fear of dying since 2
Read more

Evidence based date wise workflow logs.

 EVIDENCE BASED DATE WISE WORKFLOW LOGS  CASE 1 9/11/2023 PAJR link https://chat.whatsapp.com/D4GwL7frFWfAEuJbMXbNW8 Case report link  https://nvprathyusha100.blogspot.com/2023/11/31-yr-old-female-with-fever-since-5.html?m=1 A 31 year female came with chief complaints of fever since 5 months. Fever is high grade associated with chills and rigor , intermittent in nature, No diurnal variation It is associated with vomiting , food as content , no bilious , non projectile , no blood stained   H/o loss of appetite & weight loss  H/o burning sensation over the tongue and buccal mucosa since 3-4 months, insidious in onset, gradually progressive, aggravated when patient consumes spicy food and no relieving factors No h/o cough, cold No h/o chest pain , sob, orthopnea, pnd No h/o loose stools, constipation No h/o burning micturition, increased/decreased urine output. Not a k/c/o of HTN, DM, asthma, TB, epilepsy, CVA, CAD Vitals :  PR  : 76 bpm BP : 110/70 mmHg  RR : 20 cpm Temperature : 101
Read more