Gen med case presentation;
Jan 10 ,2022
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: 06/01/2
Chief compliants;
A 13 yr old male child who is studying 7th grade at miryalaguda high school ,brought to our opd ,with a chief complaints of
# yellowish discoloration of eyes since 9 days
# dark colored urine since 9 days .
ILLNESS EVENTS SINCE HIS BIRTH ARE As FOLLOWS;
No h/o fever,cough and cold
No h/o abdominal pain
No h/o small joint pain
PAST HISTORY;
NO h/o similar complaints in the past
he is on medication for hypothyroidism for the past 5 years
no h/o any surgeries in the past .
PERSONAL HISTORY;
DIET;mixed
APPETITE;normal
BOWEL AND BLADDER; regular but pale stools and dark urine since 9 days
SLEEP;adequate
NO KNOWN DRUG ALLERGIES
FAMILY HISTORY;
HE IS a 4th order child in his family,born out of a consanguinous marriage[grade -4]
he had one elder sister ,2 elder brother
HIS SISTER was the first child ,expired at the age of 5 years
she was alright till her age 2,then she developed SOB and was taken to hospital and got admitted
where she was diagnosed to have splenomegaly and her blood counts were decreasing
she was given multiple blood trasfusions ,every 25 days for 1 year ,but she remained anemic
she also underwent bone marrow biopsy twice
and she was given steroids for one year before her death
the parents told that she never had jaundice jaundice or recurrent infections .
FIRST ELDER BROTHER; 19 YEAR OLD -HEALTHY
SECOND ELDER BROTHER; 16 YEAR OLD
AT the age of 5 years he had fever,pale stools for which he was treated at nalgonda,he is also anemic but got treated with medications .
GENERAL EXAMINATION;
HE is conscious ,coherent ,cooperative and well oriented to time ,place ,person
he is thinly built[height ;156 cm,, weight; 32 kgs]
he has pallor,icterus ;
clubbing,cyanosis,koilonychia,lymphadenopathy,oedema _ are absent.
VITALS;
TEMP;AFEBRILE
PULSE ;80 BPM
RR;20CPM
BP;110/60 mm of hg
SYSTEMIC EXAMINATION ;
RS; BAE +
CVS;S1,S2 HEARD ,NO MURMURS
CNS; INTACT
P/A;
#INSPECTION;
SHAPE OF ABDOMEN ; schapoid
POSITION OF UMBILICUS ;CNETRAL AND INVERTED
ALL QUADRANTS OF ABDOMEN MOVING WITH RESPIRATION
NO VISIBLE SCARS AND SINUSES
NO VISIBLE PULSATIONS
#PALPATION;
SOFT
NO TENDERNESS
LIVER ;NOT PALPABLE
SPLEEN;SLIGHTLY PALPABLE
#PERCUSSION ;
NO SHIFTING DULLNESS
NO FLUID THRILL
#AUSCULTATION ;
BOWEL SOUNDS WERE HEARD
#PROVISIONAL DIAGNOSIS;
Spectrum of autoimmune disorder,
?AIHA WITH HYPOTHYROIDISM [AUTOIMMUNE THYROIDITIS]
?CVID
PRURITUS SECONDARY TO XEROSIS AND HYPOTHYROIDISM.
INVESTIGATIONS;
HEMOGRAM;
BLOOG GROUPING AND RH TYPE:
BLEEDING TIME AND CLOTTING TIME;
PROTHROMBIN TIME;
APTT;
PERIPHERAL SMEAR;
> MICROCYTES,TEAR DROP CELLS,PENCIL CELLS.
HAEMOGLOBIN ELECTROPHORESIS:
LFT;
TB;6.49
DB;0.52
AST;19
ALT;10
ALP;274
TP;5.5
ALBUMIN;3.8
SERUM LDH;265
RFT;
Sr.CR; 0.7
urea; 17
Na+; 141
k+; 4
cl-; 97
THYROID PROFILE
T3; 61
T4;8.66
TSH; 91.85
ANTI TPO ANTIBODIES;771.1
COOMBS TEST;
DCT; POSITIVE
ICT;NEGATIVE
AUTO CONTROL POSITIVE
Stool for occult blood - Negative
USG ABDOMEN;
ECG;
*TREATMENT RECIEVED ON
6/01/22; AND 7/01/22
* TAB.THYRONORM 200MICROGRAM PO/OD
*TAB.METHYL PREDNISOLONE 32 MG PO/OD
ON 8/01/22 &9/01/22
* TAB.THYRONORM 200MICROGRAMS PO/OD
* TAB.METHYLPREDNISOLONE 32MG PO/OD
* TAB.ATARAX;10MG OD [9 PM]
* PHYSIOGEL LOTION L/A , BD*2 WEEKS .
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