Case 4 splenomegaly

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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

Peripheral smear: SICKLE CELLS+

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