1801006036-long case

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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.

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A 14 year old female , resident of nagarjun sagar came to opd with a cheif complaint  of pain in both the lower limb and lower back pain since 3 days

HISTORY OF PRESENT ILLNESS 

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.

Immusnized till date.

2012

She was asymmtomatic upto age of 3 years, then she developed high grade fever with cough and vomittings. She was diagnosed with Sickle cell anaemia. Sickling test positive and Electrophoresis showed HbS. Blood transfusion were given 1packet.

2013

She developed high grade fever, dry cough and cold. She was diagnosed with Bronchopneumonia. X-ray lower lobe consolidation.

2015

She had recurrent episodes of fever, cough , cold i.e Recurrent Bronchopneumonia- 6 episodes in 3years. Urine culture showed Klebsiella growth.

Blood transfusion till date 4 times.

2016

She developed fever, pain abdomen , myalgia and arthralgia. She improved on medications and thus was discharged.

2019

She came with stomach pain and vomittings. She was diagnosed to have Acute pancreatitis.

2023

She was apparently asymptomatic  3 days back then she developed pain in left ankle for which she took TAB.ULTRACET  and since 1 day she developed pain in both knee and after 1 hr she developed tenderness in the calf muscles it is of throbbing type in nature 

No H/o of swelling 

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

No

PAST HISTORY 

she is a known case of sickle cell anemia

 H/o of bronchopnemonia

 H/o of  8 PICU admissions 

 H/o of blood transfusion (20 times till now) last transfusion was done in jan 2023

No H/O of asthama,thyroid,Tuberculosis, Hypertension, Diabetes,Epilepsy

No h/o of bone pain with localized swelling 

PERSONAL HISTORY 

Diet-mixed

Appetite-normal

Sleep-adequate

Bowel and bladder movements are regular

No allergies

No addictions 

No h/o of any surgery

FAMILY HISTORY 

3rd degree consanguity of parents

No known affected relatives

IMMUNIZATION HISTORY 

patient is vaccinated according to national immunization schedule

Pneumocccal,typhoid,hepatitis vaccine taken on 23/1/22

GENERAL EXAMINATION 

Patient was conscious, coherent and cooperative. Well oriented to time, place and person.

Pallor present

Icterus absent

Cyanosis, clubbing, lymphadenopathy, Pedal edema absent

Clinical images

Vitals

Temp: Afebrile 

PR- 96 bpm  

RR- 18/Min

Bp-110/70mm of hg

Spo2-99%

BP- 110/70 mmHg

Height-144cm

Weight-36kg

SYSTAMIC EXAMINATION 

CVS-s1 and s2 heard ,no murmurs 

RS-bilateral air entry present,normal         vesicular breath sounds are heard

CNS-no neurological deficit 

 P/A-soft and non tender

PROVISIONAL DIAGNOSIS 

Sickle cell anemia with vaso occlusion crisis

INVESTIGATIONS 

Hemoglobin-8gm/dl

TLC-22,900

PCV-23.1(normal-36 to 46)

BLOOD group -O positive 

Total bilirubin-20.15

Direct bilirubin-14.13

SGOT-170

SGPT-180

ALP-560

CRP-negative

Serology -negative

LDH-

blood urea-20mg/dl

Creatinine-0.4

Electrtrolytes-sodiun- 136 mEq/l

                           Pottasium-4.5 mEq/l

                          Chloride-101mEq/l

                           Calcium 1.02mmol/l

Peripheral smear-

  Anisopoikilocytosis with predominant Sickle cell,normocytes,few microcytes

WBC count increased

PLATELET count increased

 

X-RAY 

TREATMENT-

IV FLUID IONS@75ml/hr

TAB.PENCILLIN 800mg PO

TAB.FOLIC ACID 5mg PO OD

TAB.SHELCAL 500mg 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