#1801006186"LONG CASE

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I have 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 diagnosis and treatment plan. 

   

A 23 year old female who works in a store came to gm opd with 

 

Chief complaints :

Pain in the left side of the abdomen since 1 year 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic a 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 2-3 episodes of pain every month lasting for an hour or more 

•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) 

H/o shortness of breath since 1 year Grade 3(dyspnoea on walking some distance)

H/o easy fatiguability

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 H/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 ,moderately norished

**Pallor present**

•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: by conventional method 

Other methods 

Biannual method

Hooking method

Dipping method

No local rise of temperature and tenderness

 Spleen palpable ( moderate splenomegaly) 5cm below it's costal margin

 No palpable liver 

PERCUSSION:

liver span -11 cm (normal 6-12)

By castell's method

Spleen - dullness extending upto Umbilicus 

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

•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

INVESTIGATIONS :COMPLE  BLOOD PICTURE

2/03/2023

HAEMOGLOBIN- 8.2 gm/dl

TOTAL COUNT - 1800 cells/cumm

lymphocytes - 41%

pcv - 29.3

MCV - 78.8

MCHC - 28.0

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

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

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

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

RBC 3.75 millions/cumm

impressions -Pancytopenia

USG::

CT SCAN::

Final Diagnosis : splenomegaly with pancytopenia

TREATMENT:

• tab livogen 150mg OD

• tab ultracet 500mg SOS