1801006109 CASE PRESENTATION
long case
A 23 year old female patient store manager by occupation r came to general medicine OPD with
CHIEF COMPLAINTS
• Pain in the left side of abdomen on and off since 1 year
HISTORY OF PRESENTING ILLNESS
• Patient was apparently asymptomatic 9 years back then she started developing pain in left hypochondrium which is insidious in onset intermittent & dragging type. since last one year she is having 1-2episodes of pain every month lasting for 30-60 min.
•c/o frequent onset of fever (once in 15-20 days) since 1 year, for which she visited a local hospital and found to be having low hemoglobin & started oral iron (used for one month) for which she had black coloured stools.
•c/o shortness of breath since one year ( Grade III MMRC)
•c/o early fatigability, tingling in upper and lower limbs
•decreased appetite since 14 years of age
•No H/o chest pain, pedal edema
•No H/o orthopnea, PND
•No H/o cold , cough
•No bleeding manifestations
•No c/o weight loss
PAST HISTORY
•Not a known case of Hypertension , Diabetes mellitus , Tuberculosis , asthma , thyroid disorders, epilepsy , CVD , CAD
• No H/o surgeries in the past
FAMILY HISTORY
•No significant family history
PERSONAL HISTORY
• Diet - mixed
• appetite - decreased
• sleep - adequate
• bowel and bladder - regular
• No addictions and no known allergies
MENSTRUAL HISTORY
• age of menarche - 12 yrs
• Regular cycles , 3/28 , changes 3-4 pads per day.
• No gynecological problems
GENERAL PHYSICAL EXAMINATION
• patient is conscious, coherent, cooperative and well oriented to time, place and person.
• Thin built
• No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema
VITALS
Temperature : afebrile
Pulse rate : 70 bpm
Blood pressure :110/70 mmHg
Respiratory rate : 18 cpm
SYSTEMIC EXAMINATION
PER ABDOMEN :
• inspection
Shape - flat , no distention
Umblicus - inverted, round scar around umblicus
No visible pulsations,peristalsis, dilated veins
Visible swelling in the left hypochondrium , 6cm×4cm in size, oval shape, smooth, skin over swelling is normal
Hernial orifices are free
• Palpation
No local rise of temperature and tenderness
Spleen palpable ( moderate splenomegaly) 5cm below it's costal margin
No palpable liver
•Percussion
liver span -12 cm
Spleen - dullness extending to left lumbar region
Fluid thrill and shifting dullness absent
•Auscultation
Bowel sounds present
CARDIOVASCULAR SYSTEM:
•Inspection
Shape of chest- elliptical shaped chest
No engorged veins, scars, visible pulsations
No JVP
•Palpation
Apex beat can be palpable in 5th inter costal space medial to mid clavicular line
No thrills and parasternal heaves can be felt
•Auscultation
S1,S2 are heard
no murmurs
RESPIRATORY SYSTEM:
•Inspection
Shape of the chest : elliptical
B/L symmetrical ,
Both sides moving equally with respiration
No scars, sinuses, engorged veins, pulsations
•Palpation
Trachea - central
Expansion of chest is symmetrical.
•Auscultation
B/L air entry present . Normal vesicular breath sounds
CNS:
•HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
•CRANIAL NERVES :Normal
•SENSORY EXAMINATION
Normal sensations felt in all dermatomes
•MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
•REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
•CEREBELLAR FUNCTION
Normal function
No meningeal signs were elicited
Provisional diagnosis:-
Splenomegaly with anemia.
Complete blood picture
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APTT
BLOOD UREA- 26 mg/dl
BLEEDING AND CLOOTING TIME
BLOOD GROUPING AND RH TYPE-B positive
PROTHROMBINE TIM- 2.0sec
SERUM CREATININE - 0.6 mg/dl
HIV - non reactive
Final Diagnosis : splenomegaly with pancytopenia
TREATMENT :-
-inj. Taxim 1g OD
• inj. Pan 40g OD
• inj. Zofer OD
• tab livogen 150mg PO/OD
• tab ultracet 500mg PO/TID
• tab mvt PO/OD
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short case
Cheif complaints:
A 14 year old female,resident of nagarjuna sagar presented with cheif complaints of
Pain in lower limbs (more in right knee) and lower back pain since 6 days
History of presenting illness:-
She was apparently asymptomatic 6days back then she developed pain in left ankle initially which is progressive and since 1 day she developed pain in both knee (more on the right side>>left) which is of throbbing type in nature .
Tenderness in calf muscles is present.
No aggravating and relieving factors
No history of fever ,abdominal pain
No H/o of swelling, weakness.
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
BIRTH HISTORY:
Second child
Consanguineous 3 rd degree
All trimesters were uneventful.
-She was delivered through Caeserean section
-Birth weight of 3kg.
PAST HISTORY -
At the age of 3 she had complaints of fever,sob,fatigue, patient was diagnosed as sickle cell anemia since then She underwent multiple PRBC transfusion 20times in 11years last PRBC transfusion was in jan 2023.
H/O similar Complaints in the past for 3 times.
H/O jaundice 2yrs ago
H/O cholelithiasis 3months ago
Not a Known case of DM,HTN,CAD,CVA, EPILEPSY
IMMUNIZATION HISTORY
BCG scar present.
patient is immunised till date
PERSONAL HISTORY :
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel and bladder movements regular
No addictions
FAMILY HISTORY -
3rd degree consanguity of parents
No known affected relatives
GENERAL EXAMINATION:
Patient was conscious, coherent and cooperative.
Well oriented to time, place and person.
Moderately built and nourished.
Pallor present
Icterus present
Cyanosis, clubbing, lymphadenopathy, Pedal edema absent
Vitals
Temp: Afebrile
PR- 96bpm
RR- 18/Min
BP- 110/70 mmHg
SYSTEMIC EXAMINATION
P/A - Shape of abdomen- Normal. Umbilicus everted. No scars. No organomegaly. Bowel sounds heard.
CVS examination -
-Inspection
Shape of chest- elliptical shaped chest
No engorged veins, scars, visible pulsations
No JVP
•Palpation
Apex beat can be palpable in 5th inter costal space medial to mid clavicular line
•Auscultation
S1,S2 are heard
no murmurs
RS- NVBS.
CNS- No focal neurological deficits
Tone, power and reflexes are normal.
On examination on lower limbs bilateral calf tenderness is seen.
Clinical pictures:
Peripheral smear
X ray
Provisional diagnosis:-
Hemolytic Anaemia ?
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-
sodium- 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
Platelets and wbc were raised
Final diagnosis:-
Sickle cell anaemia with vaso occlusive crisis.
Treatment:-
IV FLUID IONS@75ml/hr
TAB.FOLIC ACID 5mg 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
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