Case 4 splenomegaly
This is 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 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.
18/3/2022
AMC BED 6
A 19 yr old male student came with c/o b/l leg pain since 16/3/22 midnight
In 2008 pt had yellowish discoloration of eyes ,visited our hospital, initially guven iron supplements i/v/o anemia, Hb was around 7 gm /dl
In 2012 pt was adviced for Hplc - which showed
Patient HbF :27.7 % ,HbAo:5.4% ,HbA2 - 4.7 ,HbS -61.3 diagnosed with sickle cell and beta thalassemia trait(i/v/o increased HbA2 ).
Father HbF : 2.8 ,HbAo:82.7, HbA2: 4.9,HbS -diagnosed with thalassemia trait (i/v/o inc.HbA2).
Mother HbF : 0.4 ,HbAo:52.4, HbA2:3.4 ,HbS 37.4 - sickling test + diagnosed with sickle cell trait.
Sister HbF : 2.2 ,HbAo:51.5 , HbA2:3.2 ,HbS 37.7 - sickling test + diagnosed with sickle cell trait.
Patient was advised to maintain adequate Fluids, avoid NSAIDS, tablet Folic acid 500 mg .
Patient had bilateral leg pain chest pain 4 years ago 1 episode, again bilateral leg pains 2 to 3 years ago and then again on 17/2/21 cured in 4 days ,on 28/2/22 cured in 6 days,on 6/3/22 cured in 6 days. Episodes of painful crisis previously once in 2 to 3 years but now the frequency increased 4th time this year.
Now patient came with complaints of bilateral hands and legs pain since one day not subsiding even after IV fluids( elbows ankle buttocks calf pains ). Patient was given IVF, injection monocef ,dolo 650 mg outside.
No complaints of fever ,vomitings, lose stools,SOB, burning micturition.
Patient went to some family function on 16/3/22 before the pain started.
O/E : Patient is C/C/C
Pallor +
No Icterus /Cyanosis /Edema of feet /Lymphadenopathy /Clubbing-
VITALS :
Temp : 98.5 F
PR : 86 bpm
BP : 130/80 mmhg
RR : 18
SPO2 : 99 % at RA
SYSTEMIC EXAMINATION :
CARDIOVASCULAR SYSTEM : S1 and S2 heard, no murmurs heard
RESPIRATORY SYSTEM : Bilateral air entry present , clear
CNS : NAD
PA : Spleen palpable
PROVISIONAL DIAGNOSIS:
ACUTE PAINFUL CRISIS K/C/O SICKLE CELL-BETA THALASSEMIA
TREATMENT:
IVF NS,RL @100 ml/hr
INJ.TRAMADOL 1 AMP in 100 ml NS iv sos
INJ. MONICEF 1 gm Iv /bd
BP,PR monitoring 2 nd hourly
Comments
Post a Comment