General Medicine
26,AUGUST,2022
A 14 year old female with chronic anemia associated with pancytopenia
E LOG GENERAL MEDICINE
Hi, I am Pindi Gayatri , 3rd Sem Medical Student.This is an 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.
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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.
CHIEF COMPLAINTS
A 14 year old female came to the OPD with the chief complaints of fever on 26th, August.
HISTORY OF PRESENT ILLNESS
She came to the OPD with the chief complaints of fever since 5 days.
She have history of low grade fever for 2 days and cough associated with sputum since yesterday night(white colour)Non blood stained.
No weight loss and abdominal pain.
Patient was asymptomatic till 7 days back,then she had low grade fever for 2 days.she went to the private hospital and found to have low hemoglobin, platelet count.Then after 5 days patient had cough associated with sputum.
HISTORY OF PAST ILLNESS
No similar complaints in the past.
It is not a known case of Hypertension, CAD, epilepsy, Asthma, Tuberculosis, Thyroid disorders etc.
TREATMENT/DRUG HISTORY
No Diabetes
No hypertension
No CAD
No Asthma
No Tuberculosis
No Antibiotics
No Hormones
No chemo/Radiation
No Blood transfusion
No surgeries
PERSONAL HISTORY
Married
Occupation-student
Diet-mixed
Appetite -normal
Bowels-regular
Micturition-normal
FAMILY HISTORY
No Diabetes
No hypertension
No Heart disease
No stroke
No cancers
No tuberculosis
No asthma
GENERAL EXAMINATION
pallor is present
No icterus
No cyanosis
No clubbing of fingers/toes
No lymphadenopathy
No oedema of feet
No malnutrition
No dehydration
VITAL SIGNS
Temperature-Afebrile
Pulse rate-77 bpm
Respiratory rate -18/min
Blood pressure -110/70 mmHg
Spo2-98%at room air
GRBS-101mg/dL
SYSTEMIC EXAMINATION
CVS
No thrills
S1S2 sounds heard
No cardiac murmurs
RESPIRATORY SYSTEM
Position of trachea-central
Vesicular breath sounds heard
No dyspnea
No wheezing
ABDOMEN
Shape of the abdomen-scaphoid
No tenderness
No palpable masses
Normal hernial orifices
No free fluid
No bruits
palpable liver-mild hepatomegaly
Palpable spleen- mild spleenomegaly
Bowel sounds are heard.
CNS
Level of consciousness-conscious/alert
Speech-normal
Signs of meningeal irritation
No stiffness of neck
Kerning's sign:negative
Reflexes
Biceps Triceps supinator knee ankle
Right ++ ++ ++ ++ ++
Left ++ ++ ++ ++ ++
Cerebellar Signs
Finger nose In-coordination:No
Knee heel In-coordination :No
Investigations
On 25th, August
Hemogram-3.38 g/dL (done outside)in other hospital .
Then She Came to OPD. Investigations adviced are Hemogram, Blood grouping.
On 26th, August
She came to OPD and then admitted In the hospital. The investigations adviced are 2D Echo and USG-Abdomen in view of organomegaly ,kidney size,any free fluid.
Ultrasound report
On 29th, August. RECORDINGS
Investigation result chart
TPR Graphic sheet
PROVISIONAL DIAGNOSIS
Chronic Anemia associated with pancytopenia.
