A 14 year girl with fever and cough

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent.

 Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case 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.

CASE SCENARIO : 

CHIEF COMPLAINTS :

A 14 years girls came to the OPD with chief complaints of fever ( low grade )  since 5 days 

Cough associated with sputum which is white in  colour and non blood stained 

No history of abdominal pain and Weight loss

HISTORY OF PRESENTING ILLNESS :

Patient was asymptomatic since 7 days back and she had low grade fever 2 days back and went to private hospital and found that she had low heamoglobin and platelets count. After 5 days she developed cough with sputum.

HISTORY OF PAST ILLNESS  :

No similar complaints in the past

Not a known case of HTN , DM, Asthma, Epilepsy, TB

PHYSICAL EXAMINATION :

GENERAL 

PALLOR : present


No Icterus 






No cyanosis , clubbing, lymphadenopathy,Edema  and dehydration.

Temperature : afebrile 

Pulse : 77 per min 

SpO2 : 100 % 

SYSTEMIC EXAMINATION :


CVS 

- Thrills : No 

- Cardiac sounds - S1 , S2 heard 

- Cardiac murmurs : No 

— RS 

- Dyspnea : No 

- Wheeze : No 

- Position of Trachea : central 

- Breath sounds :  Vescicular

— ABDOMEN 

- Shape of abdomen : Scaphoid

- No tenderness , palpable mass 

- Hernial orrifices : Normal 

- No fluids , bruits 

- Liver and Spleen are palpable
( Mild hepatosplenomegaly)

- Bowel sounds :  Yes 

CNS -
Level of consciousness : conscious
Speech : Normal
Level of conscious : Alert
No neck stiffness
Cranial system : NAD
Motor system : NAD
Sensory system : NAD


Reflexes-
                    Biceps   Triceps   Supinator  Knees  A
RL:.              +            +               +                +         +
LL:.               +            +              +                 +         +

Treatment history : Not significant

Personal history :

Diet : mixed 

Appetite : Normal 

Bowel and bladder movements : Normal 

Sleep : adequate 

INVESTIGATIONS :

25/8/22:

Blood Grouping and RH typing : O positive

Haemogram 



26/8/22 :

Random blood sugar - 91 mg/dl

Blood urea - 15 mg/dl

CRP - Negative 

ESR - 85 mm 1st hour

LDH - 212 IU/L

Reticulocyte count - 0.9 %

Serum Creatinine - 0.4 mg/dl

Serum iron - 64 ug/dl


CUE :



LFT :



Serum Electrolytes 



28/8/22 :

Haemogram 



29/8/22 :

Haemogram 




USG REPORT :




PROVISIONAL DIAGNOSIS :

SEVERE ANAEMIA WITH DECREASED EVALUATION

TREATMENT :

27/08/2022

DIAGNOSIS : SEVERAL ANAEMIA WITH       DECREASED EVALUATION

On examination patient is C/C/C

BP : 100/70 mm of Hg

PR : 80 bpm

RR : 18 cpm

SPO2 : 100% on RT

CVS : S1 , S2 heard 

Per abdomen : soft, non tender

Rx :

1. Monitor vitals

2. Inj. Optineuron in 100ml NS over 30 min IV / OD

 

28/08/2022

DIAGNOSIS : SEVERAL ANAEMIA WITH       DECREASED EVALUATION

On examination patient is C/C/C

BP : 110/70 mm of Hg

PR : 70 bpm

RR : 14 cpm 

BAE : present

Temperature : 97° F

SPO2 : 100% on RT

CVS : S1 , S2 heard 

Per abdomen : soft, not tender

Rx :

1.  Monitor vitals

2. Inj. Optineuron in 100ml NS over 30 min IV / OD

3. Inj.Iron sucrose 200mg/IV/in 100 ml NS  slow  over 1 hour


29/08/2022

DIAGNOSIS : SEVERAL ANAEMIA WITH       DECREASED EVALUATION

On examination patient is C/C/C

BP : 110/70 mm of Hg

PR : 70 bpm

BAE : present

Temperature : 98.6° F

SPO2 : 100% on RT

CVS : S1 , S2 heard 

Per abdomen : soft, not tender

Rx :

1.  Monitor Vitals

2. Inj.Iron sucrose 100mg/IV/in 100 ml NS  alternate days












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