A 20 YEAR old male with jaundice and spleenomegaly
This is 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 patient's clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered online learning portfolio and your valuable comments on 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.
Following is the view of my case:
Chief complaints:
20 year male patient came to the casualty with the chief complaints of Neck pain since 2 days
Back pain since 2 days
Fever since 1 day
Blood in urine since 1 day(one episode)
HOPI:
Patient was apparently asymptomatic 2 days back then he developed neck pain which was of dragging type and insidious in onset and gradual in progression ,non radiating and relieved on medication( aceclofenac). It is not associated with vomitings, giddiness, rigidity and loss of consciousness. Back pain was in lower lumbar region and pricking type and was continuous. Fever was insidious in onset, low grade and relieved on medication.
Past history:
Patient had hypospadias and was corrected at 6 years of age.
Patient had facial puffiness and slight edema of lower and upper limbs at 12 years of age and was found to have anaemia and one unit of blood was transfused.
He had history of jaundice 10 days back
Not a known case of diabetes, hypertension, asthma, epilepsy, tb
Family history: no similar complaints in family
Personal history:
Diet:mixed
He wakes up at 7:30 and eats rice and pickle for breakfast everyday . He takes dal and rice for lunch and curry and rice for dinner. Drinks tea in the evening.
Eats non veg twice a week.
Appetite: normal
Bowel and bladder movements: regular
Sleep :adequate(7-8 hrs)
No addictions
General examination
Patient is conscious ,coherent and cooperative .well oriented to time, place and person
Pallor present
Icterus present
No cyanosis
No clubbing
No lymphadenopathy
No oedema
Vitals:
Temperature:98.7 F
Pulse rate: 98bpm
Respiratory rate:19cpm
Bp: 120/80 mmhg
Spo2: 98% on RA
Grbs:152mg/dl
Systemic examination
Cvs:
S1 S2 present
No thrills
No murmurs
Respiratory system:
Vesicular breath sounds
Position of trachea is central
No dyspnoea
No wheeze
Abdomen:
Shape of abdomen: scaphoid
No tenderness
No palpable masses
No free fluids
Spleen: palpable below left coastal margin
Bowel sounds present
CNS:
Patient is conscious
Normal speech
No neck stiffness
Glasgow scale 15/15
Reflexes normal
Investigations
20/12/22
Hemogram (19/12/22)
Hb: 6.0
Total count: 2,500
RBC:20.6
Platelets: 1.54
Reticulocyte count:0.6%
Serum iron:34ug/dl
Serum electrolytes:
Sodium:132
Potassium :42
Chloride :102
Calcium:0.93
Blood urea:30
Serum creatinine:0.7
Lft:
Total bilirubin:2.51
Direct bilirubin:0.40
Sgot:24
Sgpt:19
Alp:158
Total proteins:6.7
Albumin:4.1
A/g ratio:1.63
LDH:110
Dengue NS1 antigen: negative
Blood for dengue test: IgM : reactive on (18/12/22)
Peripheral smear:
Microcytic hyprochromic anemia with leukopenia
Direct and indirect coombs test: negativ
e
Usg abdomen and pelvis:
Massive spleenomegaly
Size:19.8 cms
Hemogram(20/12/22)
Hb:6.0
Total count:2,200
Rbc:3.82
Platelet count:1.24
Ferritin:5.1
X ray skull
Comments
Post a Comment