19 YEAR OLD GIRL WITH CHIEF C\0 SOB......ELOG BY SAI PRANEETH BATHINEEDI

GENERAL MEDICINE CASE REPORT;

DATE:7\7\21;

SAI PRANEETH BATHINEEDI;

ROLL NO 116;

3 SEM STUDENT;

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I've 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.

I've 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 19 YEARS OLD FEMALE CAME TO THE OPD WITH CHIEF COMPLAINTS OF SHORTNESS OF BREATH(SOB) SINCE 10 DAYS;

HISTORY OF PRESENTING ILLNESS;

Patient was apparently asymptomatic 6 months ago when she experienced heavier flow of menstrual bleeding which worsened in the last 3 months and she has to use 10-15 sanitary pads for the first 2 days of her menstrual phase(5 days) as described by her;

she went to the OBG Department for the above described complaint and then she was referred to the general medicine department where she complaints of feeling SOB on speaking ,walking for 4-5 steps and even during eating for the past 10 days associated with fatigue ,weakness ,palpitations and sweating;

She also gives history of having an episode of severe SOB today morning which was relieved when she rested herself near an open window while she was made to smell camphor(suggested by an asha worker);

she C\O having intermittent episodes of sudden breathlessness at nights which worsened in the last week(it gets relieved when she stroll in the greenary for 5 minutes as described by her);

she C\O slight difficulty in breathing while lying down(which doesn't bother her much);

H\0 weight loss of 5 kg in the last month;

NO H\O Fever ,Blood in the stools, hematemesis;

PAST HISTORY;

She was born to parents of a non-consanguinous marriage with a birth weight of 3.5kg;

Breast fed for 4 years and immunization was done as per the schedule;

12 years ago: Patient was brought to KIMS(nkp) because she wasn't growing in height and was obese where she was sent for a bone marrow aspiration to KAMS,lb nagar(The result is partially known since the documents are lost)where she was given calcium and multivitamin and iron supplements which she took for 2 months;

Result of bone marrow aspiration and peripheral smear;

Cellularity-decreased cellularity as per the age;

M:E ratio-1:2 (reversed);

Erythroid series-Erythroid hyperplasia seen predominantly micro normoblast , few megaloblasts seen;

Myeloid series- myelosuppression with normal maturation seen;

Megakaryopoiesis- megakaryocytes adequate in number with hypolobated forms seen;

Lymphocytes and Plasma cells- within normal limits;

No atypical cells seen;

IMP- Dual deficiency anemia with myelosuppression;

Pancytopenia is seen in the peripheral smear;

10 years ago: she visited hospital with C\O SOB leading to difficulty in walking\playing-she was diagnosed as Hypothyroidism(she was on thyronorm-dpse,25ug initially that got increased to 75ug and then to 150ug and then decreased to 100ug over a period of time);

5 years ago: visited hospital with C\O SOB on walking(for which she was transfused with 1 unit of blood in miryalguda);

MENSTRUAL HISTORY;

Attained menarche-14 years of age;

30days cycle(5 days menses);

Pain during menses;

Clots-not present;

she has to use 10-15 sanitary pads\day for the first 2 days and 2-3 sanitary pads for the next 3 days of her menstrual phase;

FAMILY HISTORY;

Grandmother has H\O Thyroid problem;

No similar complaints in her sibling(male,1.5 years elder to her);

PERSONAL HISTORY;

Diet-mixed(prefers vegetarian);

Appetite-normal;

Sleep-reduced since 10 days;

Bowel and Bladder movements-regular;

GENERAL EXAMINATION;

Patient is conscious ,coherent and cooperative; well oriented to time, place and person;

Pallor is Present;

NO Icterus, Cyanosis, Lymphadenopathy, Pedal edema, Koilionychia;

Diffuse enlargement of the Thyroid Gland;

JVP raised;

Knuckles Hyperpigmented

VITALS;

BP-90\60mm of Hg;

RR-24 Times per minute;

PR-80 beats per minute;

SYSTEMIC EXAMINATION;

Respiratory system;

Trachea is central;

BAE +;

NVBS heard;

Cardiovascular system;

S1,S2 heard;

No Murmurs heard;

Cardiac thrill and bruit+;

Hyperdynamic apex;

Per Abdomen;

Non Tender;

Grade 3 splenomegaly(spleen extended upto umbilicus)

Hepatomegaly-Liver span-Dullness on Percussion from 6th ICS- 3cm from right costal margin;

Bowel sounds heard;

Central nervous system;

Higher mental Function Normal;

No significant findings;

PROVISIONAL DIAGNOSIS: ANEMIA UNDER EVALUATION;

? MYELODYSPLASTIC SYNDROME;

? APLASTIC ANEMIA;

PLAN: Bone Marrow Aspiration;

CLINICLAL IMAGES;

CHEST XRAY ;

COMPLETE BLOOD PANEL;

FINDINGS OF PERIPHERAL SMEAR;

RBC: Anisopokilocytosis with microcytes, macrocytes and Teardrop cells;

WBC: Reduced on smear with lymphocytosis;

PLATELET COUNT: Reduced on smear;

IMP: PANCYTOPENIA;

ECG;

COLOUR DOPPLER 2D ECHO;

ULTRASOUND;

TREATMENT;

ON 7\7\21;

1)TAB. THYRONORM 150MCG OD;

2)TAB. LASIX 40 MG BD;1-X-1;

ON 8\7\21;

1)TAB. THYRONORM 150MCG OD;1-X-1;

2)TAB. LASIX 20 MG BD;1-X-1;

3)TAB. OROFER-XT BD;1-X-1;

 

REVERSE SCAN DONE;

*PORTAL VEIN DIAMETER- 11-12mm;

*HEPATO PETAL FLOW- PSV=18cm\sec; 

IVC- MAX=16mm; MIN=12mm;