A CASE OF CHRONIC ANEMIA PRESENTED IN SUMMER OF 2022

 NOTE:

• The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed consent.

• Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

• This E-log also reflects my patient's centered online learning portfolio.

• 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 a diagnosis and providing treatment best to our skills and wisdom. 

A 14 yr old girl presented to the casualty with complaints of fever for two days.

CHIEF COMPLAINTS

➤ Fever of low grade for 2 days (5 days back)

➤ Cough with sputum (white) since 2 days 

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 7 days back . Then she had low grade fever for 2 days and was admitted to a private hospital. She was found to have low haemoglobin and platelet count . Then after 5 days she developed cough with sputum (white, non-blood stained). 

HISTORY OF PAST ILLNESS 

➤ Not a known case of diabetes ,bronchial asthma ,epilepsy, tuberculosis.

➤ No similar complaints in the past. 

PERSONAL HISTORY

➤ Patient is a student. 

➤ Patient takes mixed diet.

➤Bowel and bladder movement is normal and regular.

➤ Patient has normal menstrual cycle . 

FAMILY HISTORY 

➤No significant family history.

GENERAL EXAMINATION 

➤Pallor : Present.

➤Icterus : Not seen

➤Cyanosis : Not seen

➤Clubbing : Not seen

➤Lymphadenopathy : Not seen.

➤Edema : Not Seen.

VITALS

➤Temperature : 98.3℉

➤PR : 77 beats per minute

➤BP : 90/80 mm of Hg

➤RR : 18 cycles per minute

➤SpO2 : 100% in room air

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM EXAMINATION

➤s1 and s2 heard

➤Thrills absent.,

➤No cardiac murmurs

RESPIRATORY SYSTEM

➤Normal vesicular breath sounds heard.

➤Bilateral air entry present

➤Trachea is in midline.

ABDOMINAL EXAMINATION

INSPECTION

➤Shape - Scaphoid

➤Equal movements in all the quadrants.

➤No visible pulsation, dilated veins and localized swellings.

PALPATION

➤No tenderness

➤ Liver - Palpable: Mild Hepatomegaly.

➤ Spleen - Palpable : Mild Splenomegaly.

➤ Bowel Sounds heard.

CENTRAL NERVOUS SYSTEM EXAMINATION

➤Conscious and coherent.

PROVISIONAL DIAGNOSIS : CHRONIC ANEMIA WITH PANCYTOPENIA.

INVESTIGATIONS : 

1) HEMOGRAM 

HAEMOGLOBIN - 3.5 gm/dl

NEUTROPHILS - 12%

LYMPHOCYTES - 80%

PCV , MCV , MCHC - Decreased.

RBC COUNT - 2.52 million/cu.mm

2) BLOOD GROUPING AND Rh TYPING

3) USG ABDOMEN

No Sonological abnormalities detected.

4) TPR Graph 

5) INTAKE AND OUTPUT CHART 

TREATMENT

1) BLOOD TRANSFUSION DONE.

2) INJ. OPTINEURON in 100ml NS over 30 mins.   IV/OD.

3) INJ. IRON-SUCROSE in 100ml NS over 1hr. IV/OD.