1801006061- LONG CASE

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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.

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 3 days 

History of presenting illness:

                     

                      

Currently ,in 2023:

She was apparently asymptomatic  3 days back then she developed pain in left ankle initially which progressed 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 

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:

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.

PAST HISTORY - 

K/C/O OF sickle cell anaemia since 2012 

H/O 8 PICU admissions

history of recurrent Bronchopneumonia , 

History of sickle cell crisis in 2016

History of pancreatitis in 2019

H/O blood transfusions - done about 20 times till now and last transfusion was done in January 2023

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

No h/o of bone pain with localized swelling 

IMMUNIZATION HISTORY 

patient is immunised till date

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

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 absent

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- S1 S2 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-rays:

DIAGNOSIS:

sickle cell anemia with vaso occlusive 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

Platelets and wbc were raised 

CURRENT MANAGEMENT ( mainly pain management)

IVF NS and DNS

Inj PAN 40 mg/day

Inj OPTINUERON

inj DICLO