1801006103 short case

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I have 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.

A 23 year old female patient store manager by occupation r came to general medicine OPD with 

CHIEF COMPLAINTS 

• Pain in the left side of abdomen on and off since 1 year 

HISTORY OF PRESENTING ILLNESS 

• Patient was apparently asymptomatic 9 years back then she started developing pain in left hypochondrium which is insidious in onset intermittent & dragging type. since last one year she is having 1-2episodes of pain every month lasting for 30-60 min.

•c/o frequent onset of fever (once in 15-20 days) since 1 year, for which she visited a local hospital and found to be having low hemoglobin & started oral iron (used for one month) for which she had black coloured stools.

•c/o shortness of breath since one year ( Grade III MMRC)

•c/o early fatigability, tingling in upper and lower limbs 

•decreased appetite since 14 years of age 

•No H/o chest pain, pedal edema 

•No H/o orthopnea, PND 

•No H/o cold , cough 

•No bleeding manifestations 

•No c/o weight loss

PAST HISTORY

•Not a known case of  Hypertension , Diabetes mellitus , Tuberculosis , asthma , thyroid disorders, epilepsy , CVD , CAD 

• No H/o surgeries in the past 

FAMILY HISTORY

•No significant family history

PERSONAL HISTORY

• Diet - mixed 

• appetite - decreased

• sleep - adequate

• bowel and bladder - regular

• No addictions and no known allergies  

MENSTRUAL HISTORY 

• age of menarche - 12 yrs 

• Regular cycles , 3/28 , changes 3-4 pads per day. 

• No gynecological problems

GENERAL PHYSICAL EXAMINATION 

• patient is conscious, coherent, cooperative and well oriented to time, place and person.

• Thin built 

•  pallor present, no icterus, cyanosis, clubbing, lymphadenopathy, pedal edema

VITALS 

Temperature : afebrile

Pulse rate : 70 bpm

Blood pressure :110/70 mmHg

Respiratory rate : 18 cpm

SYSTEMIC EXAMINATION

PER ABDOMEN :

• inspection 

Shape - flat , no distention 

Umblicus - inverted, round scar around umblicus

No visible pulsations,peristalsis, dilated veins 

Visible swelling in the left hypochondrium , 6cm×4cm in size, oval shape, smooth, skin over swelling is normal 

Hernial orifices are free

• Palpation

No local rise of temperature and tenderness

 Spleen palpable ( moderate splenomegaly) 5cm below it's costal margin

 No palpable liver 

•Percussion

liver span -12 cm 

Spleen - dullness extending to left lumbar region 

Fluid thrill and shifting dullness absent

•Auscultation 

Bowel sounds present 

CARDIOVASCULAR SYSTEM:

•Inspection 

Shape of chest- elliptical shaped chest

No engorged veins, scars, visible pulsations

No JVP 

•Palpation 

Apex beat can be palpable in 5th inter costal space medial to mid clavicular line

No thrills and parasternal heaves can be felt

•Auscultation 

S1,S2 are heard

no murmurs

 

RESPIRATORY SYSTEM:

•Inspection

Shape of the chest : elliptical 

B/L symmetrical , 

Both sides moving equally with respiration 

•Palpation

Trachea - central

Expansion of chest is symmetrical.

•Auscultation

 B/L air entry present . Normal vesicular breath sounds

CNS:

•HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

•CRANIAL NERVES :Normal

•SENSORY EXAMINATION

Normal sensations felt in all dermatomes

•MOTOR EXAMINATION

Normal tone in upper and lower limb

Normal power in upper and lower limb

Normal gait

•REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited

•CEREBELLAR FUNCTION

Normal function

No meningeal signs were elicited

PROVISIONAL DIAGNOSIS : Anemia with Spleenomegaly

INVESTIGATIONS 

Complete blood picture

Hemoglobin - 8.7  gm / dl

Total WBC - 2000

PCV - 32.4 vol%

MCV - 78.6 fl

MCH - 21.6 pg

MCHC - 27.5 %

RBC count - 4.12 millions / mm³

Platelets - 55,000 / mm³

APTT - 41

Blood group - B positive 

 

ECG

USG

CT SCAN

Bone marrow biopsy 

diagnosis : splenomegaly with pancytopenia

TREATMENT :-

 -inj. Taxim 1g OD

• inj. Pan 40g OD

• inj. Zofer OD

• tab livogen 150mg PO/OD

• tab ultracet 500mg PO/TID

• tab mvt PO/OD