FINAL PRACTICAL EXAM CASE-1

 THIS IS AN 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

February 9th 2022
A 13 year old female came to OPD with complaints of abdominal pain since 2 days associated with two episodes of vomiting.


HISTORY OF PRESENTING ILLNESS -

Patient was apparently asymptomatic 2 days ago then developed epigastric pain on radiation, moderate severity and gradually progressive, non radiating
2 episodes of vomiting since 2 days with food as content and non bilious non projectile no relation to feeds

PAST HISTORY - 
K/C/O of sickle cell anaemia since 2012 

History of sickle cell crisis 2016 

History of pancreatitis 2019

Last blood transfusion 2020

PERSONAL HISTORY:

Diet- mixed 

Appetite-normal 

Sleep- adequate 

Bowel and bladder movement- normal 

No addictions 

Family history- no relavent family history

TREATMENT HISTORY
patient is currently using
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 500 OD


IMMUNIZATION HISTORY:

Patient is vaccinated according to National immunization schedule,
Pneumococcal, typhoid, hepatitis vaccine taken on 23/1/22

GENERAL EXAMINATION: 
Patient is conscious coherent and cooperative 

Pallor - present 

Icterus- present 

No cyanosis clubbing lymphadenopathy edema

VITALS - 
TEMPERATURE - 97' F 
PULSE RATE - 90 BPM
BLOOD PRESSURE - 110/70 MM OF HG 
RESPIRATORY RATE - 26cpm
SPO2 - 99 % AT ROOM AIR
HT - 144 cm
WT - 36 kg

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  

Investigations:



USG ABDOMEN
1- bulky pancreas 
2- cholelithiasis


Provisional diagnosis

Abdominal pain secondary to pancreatitis and known case of sickel cell anemia 

Clinical images

TREATMENT PLAN

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 











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