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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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan
CONSENT AND DEIDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever .
Case history :
14 yr old male came to the opd with complaints of pain abdomen in the left side of the abdomen since the past 15-20 days along with cold and cough since the past 10 days.
He was having pain abdomen and noticed a swelling in the left side of the abdomen since the past 15-20 days along with cold and cough associated with scanty sputumA for the past 10 days. On asking him to elaborate about pain abdomen, it was of dragging type, non radiating, no associated symptoms and was started on symptomatic management.
General examination showed thin built moderately nourished with pallor with cervical and inguinal lymphadenopathy and massive splenomegaly
General examination:
Initial investigations revealed
HEMOGRAM :
HAEMOGLOBIN #7.8
TOTAL COUNT ＃ 1.600
NEUTROPHILS ＃31
LYMPHOCYTES ＃42
EOSINOPHILS # 09
MONOCYTES＃18
BASOPHILS 100
PCV #24.8
MCV #76.5
MCH # 24.0
MCHC # 314
RDW-CV # 19 3
RDWV-SD 53 9
RBC COUNT # 3.25
PLATELET COUNT 20,000
LIVER PROFILE :
Total Bilurubin 0.79
Direct Bilurubin 0.18
SGOT(AST) 10
SGPT(ALT) 15
ALKALINE PHOSPHATE 163
TOTAL PROTEINS #4.5
ALBUMIN # 2.6
A/GRATIO 1.43
RENAL FUNCTION :
Blood urea 10
Serum creatinine 0.5
Sodium 134
Potassium 3.4
Chloride 104
ionised calcium 0.93
LDH 120
Reticulocyte count 0.5
Chest x ray PA view :
USG Abdomen showing portal vein dilatation of 16mm and massive splenimegaly with no ascites.
USG neck showing
1.Diffuse thyroiditis with thyroid nodule in left lobe
2.Bilateral submandibular gland, sialo adenitis secondary to inflammatory changes
3.mild parotiditis with enlarged parotid lymph nodes.
FEVER CHART :
Family history :
He is a 4th order child ,born out of grade 4 consanguinous marriage, He has 2 elder brothers and one elder sister - who expired at 5 years of age, His sister was the first child and she was assymoptomatic till 2 years of age ,then she had shortness of breath and was rushed to hospital,where here condition detiorated and got admitted .They were told that she had splenomegaly and Her blood counts were decreasing .She was given multiple blood transfusions every 25 days for one year inspite of that she remained anemic ,she also underwent bone marrow biopsy twic, was advised splenectomy, but they denied. According to parents she was given steriods also for one year before death .she never had jaundice or recurrent infections.
Elder brother is 19 year old and second brother is -16 years old . Second one had history of fever ,white coloured loose stools at the age of 5 years ,for which they went to near by hospital .He was given some medications and it got resolved .But he was said to have anemia ,and he recovered according to parents with some medications.There was no jaundice and no history of blood transfusion.
Patient's birth history :
He is the youngest of all. He was born out of normal vaginal delivery with 4.25kgs birth weight, cried immediately after birth. He had jaundice at birth ,that resolved spontaneously .? Physiological jaundice. He is Immunised as per schedule .
INITIAL PROBLEM
Around 12months of his age, he was brought with complaints of Not gaining weight since last 3 months with delayed mile stones since last 3 months, loose motions/ vomitings on & off since 3 months.
He was apparently normal 3 months back than child was not gaining weight, loose
motions greenish in colour, watery in character 25 - 30 times a day, not associated with blood & mucus, vomitings 4 - 5 times, non bilious/ non projectule, , History of recurrent cough and cold .
During the hospital stay he was admitted in ward started IV fluids and blood investigations were sent blood investigation were s/o severe Hypokalaemia as low as 1.5 with leucocytosis, Child potassium was corrected over 24 - 26hours, child stool examination showed bacteria ( E. coli ) and child started on IV antibiotics along with IV anti fungal, Child responded well and general condition improved day by day, Child given 2 units of FFP and child started on oral diet, avoiding wheat diet, child shown to another Paediatrician Suspected as celiac disease, Child blood sent for Anti endomysial antibodies, ( no availability of report ) his general condition improved and stool consistency changed to semisolid, child parents were counselled about the oral diet and was discharged
On further asking parents, they told he used to have recurrent colds ,cough and fever. He used inhalers for 1 year during winters in childhood though he wasn't admitted at any point, and there was no history of pneumonia.
Childhood history :
At 9 years of age August, 2016 - parents noticed neck swelling and he had difficulty in swallowing they took him to ENT doctor ,later referred to endocrinologist ,where he was diagnosed with hyperthyroidism,
At 12 years of age patient had chicken pox ,resolved over 10 days.
Around late part of December 2021
He gave history of yellowish discoloration of eyes, One episode of bilious vomiting. yellow coloured urine, He was treated by a pediatrician (family doctor) for jaundice ,but as the bilirubin was on increasing trend he was referred to our hospital in the first week of January with the history of above said complaints of 7-10 days
No pale colored stools .
No fever ,pain abdomen ,loose stools.
No cold, cough .
No history of small joint pains .
At that time of presentation :
On examination -
He was thin built .
Height -156 cm
Weight - 32kgs
Jaundice + ,pallor +
Per abdomen -soft, non tender with moderate splenomegaly
Outside investigations -
There is significant drop in hemoglobin from 8.9 to recent HB -5,leucopenia , thrombocytopenia.
With raised bilirubin - both direct and indirect, normal enzymes .
Urine for bile salts and bile pigments + ve
HB electrophoresis - normal .
Dengue , Malaria ,widal was negative
Hemogram showed -
Normocytic normochromic anemia with HB 5.1
WBC count -1700 ,neutrophils -39% ANC-663 ,Esoniphils -8% .
Platelet count -1.5 lakh
With few microcytes ,tear drop cells ,pencil forms.
Liver profile showing total bilirubin of 6.49,
USG abdomen showing moderate splenomegaly.
pancytopenia with massive splenomegaly
plan of treatment
1.Inj. Neomol 1gm IV SOS
2.Tab dolo 650 mg PO SOS
3.Tab. Levocetrizine 5mg PO SOS
4.Syrup ascoril 10 ml PO BD
5.tab. thyronorm 200mcg, PO OD
6.inj. optineruron 1 amp
7. BP temp charting 6th hourly
