General medicine Long Case

 9 Feb 2022

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CHIEF COMPLAINT:

A 13yr old female patient presented to the opd with chief complaint of abdominal pain since 2 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 days ago then she developed epigastric pain radiating with moderate severity and gradually progressive.

2 episodes of vomiting since 2 days with food as content and non bilious non projectile

PAST HISTORY 

Pt is a known case of sickle cell anaemia since 2012 

History of sickle cell crisis 5 yrs ago

History of pancreatitis 2 yrs ago

Last blood transfusion  1 yr ago

PERSONAL HISTORY :

Diet- mixed

Appetite-normal

Bowel movement - regular 

Bladder movements - regular 

Addictions(alcohol and smoking) - no addictions

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 od

T. Liv 500mg OD

FAMILY HISTORY - 

No family history 

GENERAL EXAMINATION : 

Patient is conscious , coherent, co-operative

ICTERUS present, 

PALLOR present, 

No CLUBBING , CYANOSIS , LYMPHADENOPATHY, EDEMA

VITALS - 

TEMPERATURE - afebrile

PULSE RATE - 90 bpm

BLOOD PRESSURE - 110/70 mm of hg

RESPIRATORY RATE - 26cpm

SPO2 - 99 % AT ROOM AIR

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

IMMUNIZATION HISTORY

Patient is vaccinated according to National immunization schedule,

Pneumococcal, typhoid, hepatitis vaccine taken on 23/1/22

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 

USG ABDOMEN

1- bulky pancreas 

2- cholelithiasis

PROVISIONAL DIAGNOSIS:

Pain abdomen secondary to acute pancreatitis, known case of sickle cell anaemia

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