Final practical short case

 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 SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 


February 1 2022 ( date of admission)

A 13 year old female came to OPD with complaints of abdominal pain since 2 days associated with two episodes of vomitings

HISTORY OF PRESENTING ILLNESS -

Patient was apparently asymptomatic 2 days ago then she developed epigastric pain which is severe and radiating ,gradually progressive, 2 episodes of vomiting since 2 days with food as content .

PAST HISTORY - 

K/C/O sickle cell anaemia since 2012  

History of bronchopneumonia

History of sickle cell crisis 2016

Hitory of pancreatitis 2019

Last blood transfusion 2020

PERSONAL HISTORY :

DIET - MIXED,

APPETITE -NORMAL ,

BOWEL MOVEMENT - REGULAR , 

BLADDER MOVEMENTS - REGULAR, 

ADDICTIONS(ALCOHOL AND SMOKING) - NO ADDICTIONS

SLEEP - Adequate


FAMILY HISTORY 

Similar complaints in the family is seen 

IMMUNIZATION HISTORY: 

Patient is vaccinated according to National immunization schedule,

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


GENERAL EXAMINATION:

PATIENT IS CONCIOUS , COHERENT COOPERATIVE

ICTERUS present, 

PALLOR present, 

No CLUBBING , CYANOSIS , LYMPHADENOPATHY, EDEMA

VITALS - 

TEMPERATURE - 97' F

PULSE RATE - 90 BPM

BLOOD PRESSURE - 110/70 MM OF HG 

RESPIRATORY RATE - 26 cpm

SPO2 - 99 % AT ROOM AIR

HT - 144 cm

WT - 36 kg

SYSTEMIC EXAMINATION - 

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

CENTRAL NERVOUS SYSTEM : NAD

PER ABDOMEN - DIFFUSE TENDERNESS PRESENT, NO ORGANOMEGALY


INVESTIGATIONS:

DIAGNOSIS: 

sickle cell anemia

Acute pancreatitis secondary to cholelithiasis ?

Secondary to pneumonia with right lower lobe consolidation..

TREATMENT HISTORY: 

patient is currently on

T. Hydroxyurea 1000mg po OD

T. Benzylpenicillin 600 mg po OD

T. Sodamint TID

T. Folate 5mg po OD

T. Calcium 500mg po OD

T. Zincovit po od

T. Liv 52 OD


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