Gm final practical:long case
09.02.22
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Chief complaint:
A 13 year old female came to OPD with complaints of abdominal pain since 2 days and 2 episodes of vomiting since 2 days.
HISTORY OF PRESENTING ILLNESS -
Patient was apparently asymptomatic 2 days ago then develop epigastric pain on radiating moderate severity and gradually progressive.
PAST HISTORY
Pt is a known case of sickle cell anaemia since 2012
History of sickle cell crisis 2016
History of pancreatitis 2019
Last blood transfusion 2020
PERSONAL HISTORY :
DIET - MIXED,
APPETITE -NORMAL ,
BOWEL MOVEMENT - REGULAR ,
BLADDER MOVEMENTS - REGULAR,
ADDICTIONS(ALCOHOL AND SMOKING) - NO ADDICTIONS
FAMILY HISTORY -
No family history
TREATMENT HISTORY
patient is currently on
T. Hydroxyurea 1000mg po OD
T. Benzylpenicillin 600 mg po OD
T. Sodamint TID
T. Folate 5mg po OD
T. Calcium 500mg po OD
T. Zincovit po od
T. Liv 52 OD
IMMUNIZATION HISTORY
Patient is vaccinated according to National immunization schedule,
Pneumococcal, typhoid, hepatitis vaccine taken on 23/1/22
ON EXAMINATION -
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
ICTERUS present,
PALLOR present,
No CLUBBING , CYANOSIS , LYMPHADENOPATHY, EDEMA
VITALS -
TEMPERATURE - 97' F
PULSE RATE - 90 BPM
BLOOD PRESSURE - 110/70 MM OF HG
RESPIRATORY RATE - 26 BPM
SPO2 - 99 % AT ROOM AIR
HT - 144 cm
WT - 36 kg
SYSTEMIC EXAMINATION -
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
P/A - diffuse tenderness present, no organomegaly
INVESTIGATIONS:
Serum lipase #570 IU/L (13- 60)
Serum creatinine #0.4 mg/dl (0.5 -1)
SERUM ELECTROLYTES
Sodium 140 mEq/L
Potassium 4.2 mEq/L
Chloride 101 mEq/L
Blood urea :46 mg/ dl(12-42)
Blood investigations:
HB #7.9 gm /dl(12-15)
Total count #16,400 cell/cumm(4000-10000)
Neutrophils 75 %(40-80)
Lymphocyte #17%(20-40)
MCHC #37.6 % (31.5 -34.5)
RBC count # 2.50 millions per cumm( 3.8-4.8)
LIVER FUNCTION TESTS
Total bilirubin #20.5qmg/dl(0-1)
Direct bilirubin #14.13mg/dl(0.0-0.2)
SGOT #170 IU/L(0-31)
SGPT #180 IU/L (0-34)
Alkaline phosphatase #566(54-369)
Serum amylase #944 IU/L ( 25-140)
Blood urea 13 mg/dl
LDH #543 IU/L (230 -460)
BLOOD GROUPING
O+VE
COLOUR DOPPLER 2D ECHO
Clinical images:
Treatment:
IVF NS/DNS AT 75 ML/HR
INJ. PAN 40 MG IV OD
INJ. OPTINEURON 1 AMP IN 100 ML NS OVER 30 MINS
INJ. TRAMADOL 1 AMP IN 100 ML NS OVER 30 MINS
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