a 14 yrs old female patient

This is online E log book to discuss our patients health data shared after taking his guardians informed consent form

I have been given this case to solve in an attempt to understand topic of" patient clinical data analysis" to develop my competency in reading and comprehensing clinical data including history clinical findings
 investigations and come with a diagnosis and treatment plan. 

This is a case of 14 yr old female diagnosed with Sickle cell anaemia have multiple admissions for sickle cell crisis now presented with chief complaints of 
      - Joint pains more at night 
       - Right knee pain since 15 days 
       - left leg shin pain
HOPI
Patient was apparently asymptomatic 10 yrs back and diagnosed as Sicke cell anaemia
with known history of Abdominal pain, yellowish discoloration of eyes,SOB,fever,dry cough, pleural tap and she had blood transfusion 15 times since childhood and had multiple episodes of sickle cell crisis and brochopneumonia and pancreatitis for which she was admitted and treated.She was on her regular medication hydroxy urea 100 mg daily once .Now she presented with complaints of left knee pain and right shin and calcaneal region pain relieved on diclofenac i.m stat.

PAST HISTORY 
N/K/C/O DM,HTN,EPILEPSY
History of blood transfusions
She was having jaundice 2-3 yrs back with complaints of lower epigastric pain and SOB and occasional palpitations,for which she recieved 1 blood transfusion.

PERSONAL HISTORY
Appetite is normal
Mixed diet
Regular bowel and bladder movements
No known allergies

FAMILY HISTORY
No significant family history

GENERAL EXAMINATION
On examination pt is c/c/c
 well oriented with time and place .
Well nourished and built
No signs of 
 pallor ,cyanosis, lymphadenopathy,icterus,clubbing,edema of , Malnutrition, dehydration.

Temp:98.4F
Pulse rate: 86/ min
SpO2 : 98%
BP: 110/80 mm Hg
Hb: 8.6 

LIMB EXAMINATION
Left knee pain,Rt shin pain,
Normal skin 
No swelling 
No local rise of temp
No tenderness
SYSTEMIC EXAMINATION
 On examination pt is c/c/c
 Afebrile
CVS: S1,S2 +
L/S : BAE+ 

PROVISIONAL DIAGNOSIS
SICKLE CELL CRISIS

INVESTIGATIONS
TREATMENT 
Inj.Diclofenac 1 amp for 24 hrs
1 PRBC Transfusion plan


Comments

Post a Comment

Popular posts from this blog

final exam long case

Image
This is an online elog book to discuss our patients 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 problems with collective current best evidence based inputs.This elog book reflect s my patients centered online portfolio and your valuable inputs on the comments is welcome.    Chief complaint -  A 54 yrs old male patient of resident suryapet, shop keeper by occupation came to opd with chief complaint of pedal edema from 1 month and fever from 4 days.  History of present illness- Patient was apparantly asymptomatic 6months months back and then he developed  fever   associated with chills , rigor and vomitings. He was admitted in local hospital and was found to have raised creatinine levels and diagnosed as renal failure. He was under observation for 10days and treated . He was on
Read more

27 yr old male patient with Acute gastro enteritis

Image
 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 a series of inputs available global online community of experts with the aim to solve the patient’s clinical problems with the collective current best evidence based inputs. This E log reflects my patient centred online learning portfolio and your valuable inputs in the comments section. 27 year old male came to OPD with complaints of fever for 5 days, abdominal discomfort since 5 days, nausea, vomiting ,loose stools since 5 days, burning micturition since 3 days.  Patient was apparently asymptomatic 5 days back who works as a car driver since 5 years who was occasional Toddy drinker ( 1 glass of intake for any occasional festival )  5 days ago he went to function where he consumed 1 litre of Toddy along with red meat , following next day he experienced pain abdomen which was squeezing
Read more

a 45 yrs old male patient

Image
 A patient who is 45 yr old male came to OPD with chief complaints of fever since 2 days and slurring of speech since 1 day and pain in both lowerlimbs . HISTORY OF PRESENT ILLNESS     Patient is a daily wage worker by occupation . Patient was apparently asymptomatic 2 years back then his appetite increased( about 5- 6 times a day ) for which he came to KIMS hospital and diagnosed with Diabetes.He used oral hypoglycemic drugs for first 6 months.Then from past 1.5 years he is on insulin.He was a chronic alcoholic since 25 yrs. He consumes more than 180ml / day . Urine output increased since 2 years about 10 times a day.Decreased weight about 25kg since 2 years. Then since 2 days he developed fever which was high grade, continuous and associated with chills and rigor and also presence of neck stiffness and burning Micturition.Patient was also anemic for which he received blood transfusion   He developed slurring of speech since 1 day then he came to hospital the next day HISTORY OF PA
Read more