1801006105 SHORT CASE

 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.

14yr old female resident of Nalgonda has presented with complaints of pain in both knees  since 6 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 HISTORY 

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

H/O similar Complaints in the past for 3times

H/O jaundice 2yrs ago

H/O cholelithiasis 3 months ago

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

Previous blood transfusion done

PERSONAL HISTORY:

Diet is mixed

Appetite is normal

Regular bowel and bladder 

Known dust allergies 

FAMILY HISTORY:

No relevant family history 

GENERAL PHYSICAL EXAMINATION:

Patient is conscious coherent and co-operative 

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%

SYSTEMIC EXAMINATION-

CVS-

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

Palpation-apical beat is present 

Auscultation -s1,s2 heard

P/A -

Inspection-abdomen flat,no scars and visible peristalsis

Palpation- no organomegaly

auscultation-bowel sounds heard

RS-

normal vesicular sounds heard ,no added sounds.

CNS-

Higher mental functions intact

Tone ,reflex,power normal.

DIAGNOSIS:

Vasoocclusive crisis secondary to sickle cell disease.

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

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