1801006171 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. 

23 year old female who has a general store came to gm opd with 

 

Chief complaints :

Pain in the left side of the 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 .she had visited local unregistered medical practitioner with complaints of pain and recieved painkillers. 

since last one year she is having 2-3 episodes of pain every month lasting for an hour or more 

• 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) . change in colour of stool is observed after intake of tablets 

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  

General examination 

Pallor present 

•icterus, cyanosis, clubbing, lymphadenopathy, pedal edema  are absent 

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

No visible pulsations,peristalsis, dilated veins 

Visible swelling in the left hypochondrium , about 3x4cm in size, ovoid in shape,  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

https://youtube.com/shorts/_vXhQ_6T5FE?feature=share

No palpable liver 

PERCUSSION:

liver span -11 cm (normal 6-12)

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 raised 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 : normal 

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

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

ECG

Ultra sound

Ct abdomen

 bone marrow biopsy 

Final Diagnosis : splenomegaly with pancytopenia

TREATMENT :-

• tab livogen and ultracet  sos