Long case 1801006114

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 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 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-centred online learning portfolio and your valuable inputs on the 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.


A 23 year old female patient store manager by occupation 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 the she started developing pain in left hypochondrium insidious in onset intermittent & dragging type. since last one year multiple episodes 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)

•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 

Timeline of illness 






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 , 

• hyperpigmentation of tongue 











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.


•Percussion

 Resonant 


•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 : anemia with splenomegaly 


INVESTIGATIONS 

 25/02/2023


HAEMOGLOBIN- 8.9 gm/dl
TOTAL COUNT - 2000 cells/cumm
pcv - 32.4
MCV - 78.6
MCHC - 27.5
RDW-CV 25.2
smear- microcytic hypochomic with leucopenia and thrombocytopenia

26/02/2023
HAEMOGLOBIN- 8.8 gm/dl
TOTAL COUNT - 2600 cells/cumm
pcv - 32.8
MCV - 79.0
MCHC - 26.8
RDW-CV 25.3 %
smear- microcytic hypochomic with leucopenia and thromobocytopenia

27/02/2023


HAEMOGLOBIN- 8.7 gm/dl
TOTAL COUNT - 2000 cells/cumm
pcv - 31.9
MCV - 78.6
MCHC - 27.3
RDW-CV 24.5
smear- microcytic hypochromic with leucopenia and thrombocytopenia

28/02/2023


HAEMOGLOBIN- 8.0 gm/dl
TOTAL COUNT - 1660 cells/cumm
lymphocytes -  41%
monocytes - 12%
pcv - 28.5 
MCV - 78.3
MCHC - 26.1
RDW-CV 24.6
smear- microcytic hypochromic with leucopenia and thrombocytopenia

1/03/2023



HAEMOGLOBIN- 8.9 gm/dl
TOTAL COUNT - 2000 cells/cumm
pcv - 32.4
MCV - 78.6
MCHC - 27.5
RDW-CV 25.2
smear- microcytic hypochromi with leucopenia and thrombocytopenia

2/03/203


HAEMOGLOBIN- 8.2 gm/dl
TOTAL COUNT - 1800 cells/cumm
lymphocytes - 41%
pcv - 29.3
MCV - 78.8
MCHC - 28.0
RDW-CV 24.6
smear- microcytic hypochromic with leucopenia and thrombocytopenia

4/03/2023



HAEMOGLOBIN- 8.7 gm/dl
TOTAL COUNT - 2130 cells/cumm
pcv - 30.0
MCV - 789     
MCHC - 28.6
RDW-CV 24.6
smear- Anisocytosis with normocytes microcytes tear drops pencil forms and macrocytes
impressions -Pancytopenia

7/03/2023



HAEMOGLOBIN- 9.2 gm/dl
TOTAL COUNT - 2000 cells/cumm
monocytes - 13%
pcv - 33.4
MCV - 82.1
MCHC - 27.5
RDW-CV 24.5
smear-  Anisocytosis with normocytes microcytes tear drops pencil forms and macrocytes
impressions -Pancytopenia 

9/03/2023



HAEMOGLOBIN- 9.8 gm/dl
TOTAL COUNT - 2600 cells/cumm
pcv - 34.3
MCV - 80     
MCHC - 28.6
RDW-CV 24.5
smear-  Anisocytosis with normocytes microcytes tear drops pencil forms and macrocytes
impressions -Pancytopenia

12/03/2023



HAEMOGLOBIN- 8.8 gm/dl
TOTAL COUNT - 2000 cells/cumulative
lymphocytes - 42%
pcv - 30.1
MCV - 80.3
MCH - 23.5
MCHC - 29.5
RDW-CV 22.5
RBC 3.75 millions/cumm
smear-  Anisocytosis with normocytes microcytes tear drops pencil forms and macrocytes
impressions -Pancytopenia


13/03/2023

HAEMOGLOBIN- 8.7 gm/dl
TOTAL COUNT - 2000 cells/cumm
pcv - 29.8
MCV - 80.5
MCH - 23.5
MCHC - 29.5
RDW-CV 22.5
RBC - 3.70millipns /cum
smear-  Ansocytosis with normocytes microcytes tear drops pencil forms and macrocytes
impressions -Pancytopenia


Other investigations 

APTT Result- 41s

BLOOD UREA- 26 mg/dl
BLEEDING AND CLOOTING TIME

bleeding time - 2min
clotting time -4min

BLOOD GROUPING AND RH TYPE-B positive


PROTHROMBINE TIM- 2.0sec


SERUM CREATININE - 0.6 mg/dl



HIV - non reactive


Anti HCV antibodies -non reactive

 

ECG

USG


CT

                BONE MARROW ASPIRATION 



BONE MARROW BIOPSY

 

  
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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