Gen med case presentation;
Oct 30,2021
Name;Ramya reddy pebbeti.
Roll no;105 .
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 patients’ clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient centred online learning portfolio and your valuable inputs 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 diagnosis and treatment plan
Following is the view of my case :
CASE PRESENTATION ;
DOA:17/11/21
chief compliants:
A 16 yr old female , studying 1 yr intermediate came to the OPD with yellowish discoloration of eyes Since 5 days
Vomiting since 4 days
HOPI:
She is born out of a 2 degree consanguinous marriage in 2005 and, AT the age of 3 yrs she was diagnosed to have asthma for which she is using medicine and she also complaints that she is having recurrent episodes of cough with sputum and also fever for which she uses medication during the episodes.
in February 2021 ,she had yellowish discoloration of eyes , fever ,cough for which she went to hospital and she got treated , she has anemia for which she is taking oral iron supplements and from March 2021 ,she is receiving IVIG ONCE MONTHLY,now she came to the opd complaining of yellowish discoloration of eyes since 5 days which is insidious in onset and from 2 days the yellowish discoloration has progressed to palms and soles.
She also complainted of vomiting ,which is insidious in onset and non projectile, non bilious and contents being food . She had rash over the limbs d/t mosquito bite.
H/o Passage of Dark coloured urine since 3 days
No h/o abdominal pain and distension
No h/o Passage of pale stools
No h/o rash over the body
General examination;
She is conscious, coherent, cooperative and we'll oriented to time,place and person.
She is thinly built.
Pallor _ present
Icterus - present
Cyanosis, lymphadenopathy,edema - absent
VITALS:
TEMP;afebrile
PR:80bpm
BP:120/80mm of Hg
RR:16 cpm
Nystagmus: present(horizontal)
Systemic examination;
RS: BAE+
CVS: S1 ,S2 HEARD
CNS: INTACT
PER ABDOMEN;
Inspection;
Shape of abdomen: scaphoid
Position of umbilicus; central and everted
No scars and sinuses
Palpation;
No tenderness
No hepatomegaly and splenomegaly
Percussion;
No fluid thrill and shifting dullness
Auscultation;
Bowel sounds are heard
Provisional diagnosis;
Acute on chronic hemolytic anemia
CVID WITH AUTOIMMUNE HEMOLYTIC ANEMIA.
USG:
On 18/11/21 ,LFT;
LFT on 19/11/21
TB; 33.67
DB;23.2
AST;134
ALT:138
ALP;181
Total protein:5.6
Albumin;3.68
A/G RATIO;1.92
On 22/11/21 , yellowish discoloration decreased
Treatment;
Tab.prednisolone 20 mg po OD
Tab. Doxy 50 mg po OD
Tab.folvite 5 mg po OD
Tab.orofer - XT po OD
Syp.digestive enzymes
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