A 13 year old male with jaundice

-

 


CASE DISCUSSION FOR PRACTICAL EXAMINATION ;INTERNALS

 Gen med case presentation;

Jan 10,2022

Name: E.RishithaReddy 

 Roll no: 30



This is 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 patients’ clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome. 

 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



Following is the view of my case :

CASE PRESENTATION ;
DOA: 06/01/2022

Chief compliants; 


A 13 yr old male child who is studying 7th grade  at miryalaguda high school ,brought to our opd ,with a chief complaints of 
   # yellowish discoloration of eyes since 9 days
   # dark colored urine since 9 days . 

History of presenting illness-

Patient was apparently asymptotic  9days back.
Has h/o- yellowish discolouration of eyes since 9 days
Has history of mild cold and cough since 9days.
H/o -dark coloured urine since 9 days 
Has h/o-Vomiting -green coloured 9days back two episodes
Has h/o -pruritis since 5 yrs 


Negative history -

Has no h/o- fever , weakness, headache , shortness of breadth, abdominal pain ,gynecomastia , burning micturation , 



ILLNESS EVENTS SINCE HIS BIRTH  ARE As FOLLOWS;





PAST HISTORY;

NO h/o similar complaints in the past
he is on medication for hypothyroidism for the past 5 years
no h/o any surgeries in the past .

PERSONAL HISTORY; 

DIET;mixed
APPETITE;normal
BOWEL AND BLADDER; regular but pale stools and dark urine since 9 days 
SLEEP;adequate
NO KNOWN DRUG ALLERGIES

FAMILY HISTORY;

 HE IS a 4th order child in his family,born out of a consanguinous marriage[grade -4]
he had one elder sister ,2 elder brother

 HIS  SISTER was the first child ,expired at the age of 5 years
 she was alright till her age 2,then she developed SOB and was taken to hospital and got admitted 
where she was diagnosed to have splenomegaly and her blood counts were decrease 
she was given multiple blood trasfusions ,every 25 days for 1 year ,but she remained anemic
she also underwent bone marrow biopsy twice 
and she was given steroids for one year before her death
the parents told that she never had jaundice or recurrent infections .

FIRST ELDER BROTHER; 19 YEAR OLD -HEALTHY

SECOND ELDER BROTHER; 16 YEAR OLD 
 AT the age of 5 years he had fever,pale stools for which he was treated at nalgonda,he is also anemic but got treated with medications .

GENERAL EXAMINATION;

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

he is thinly built[height ;156 cm,, weight; 32 kgs]

he has pallor,icterus ;









clubbing-absent
cyanosis-absent
koilonychia-absent
lymphadenopathy-absent
oedema -absent.
 
VITALS;
TEMP;AFEBRILE
PULSE ;80 BPM
RR;20CPM
BP;110/60 mm of hg

SYSTEMIC EXAMINATION ;
RS; BAE +
CVS;S1,S2 HEARD ,NO MURMURS
CNS; INTACT
P/A;
#INSPECTION;
 SHAPE OF ABDOMEN ; scaphoid 
POSITION OF UMBILICUS ;CENTRAL AND INVERTED
ALL QUADRANTS OF ABDOMEN MOVING WITH RESPIRATION
NO VISIBLE SCARS AND SINUSES
NO VISIBLE PULSATIONS

#PALPATION;
SOFT
NO TENDERNESS 
LIVER ;NOT PALPABLE
SPLEEN;SLIGHTLY PALPABLE 

#PERCUSSION


NO SHIFTING DULLNESS
NO FLUID THRILL

#AUSCULTATION ;

BOWEL SOUNDS WERE HEARD

CVS - s1 and s2 are heard , no added murmurs
Respiratory system- bilateral air entry present, vesicular breath sounds
Cns- no focal neurological deficit

#PROVISIONAL DIAGNOSIS;

Spectrum of autoimmune disorder,
     ?AIHA WITH HYPOTHYROIDISM [AUTOIMMUNE                 THYROIDITIS]
     
   


INVESTIGATIONS;

HEMOGRAM;




BLOOG GROUPING AND RH TYPE:




BLEEDING TIME AND CLOTTING TIME




PROTHROMBIN TIME;





APTT;




HAEMOGLOBIN ELECTROPHORESIS



LFT:



 TB-6.49
DB-0.52
AST-19
ALT-10
ALP-274
TP-5.5
ALBUMIN-3.8

SERUM LDH-265

RFT:

Sr.CR- 0.7
urea-17
Na+- 141
k+-4
cl- 97

THYROID PROFILE -
 T3-61
T4- 8.66
TSH- 91.85
ANTI TPO ANTIBODIES- 771.1

COOMBS TEST;
DCT- POSITIVE 
ICT- NEGATIVE
AUTO CONTROL POSITIVE 

Stool for occult blood - Negative

USG ABDOMEN;




ECG;





TREATMENT RECIEVED ON  
6/01/22;  AND 7/01/22
 *  TAB.THYRONORM 200MICROGRAM PO/OD
  *TAB.METHYL PREDNISOLONE 32  MG PO/OD

ON 8/01/22 &9/01/22
*   TAB.THYRONORM 200MICROGRAMS PO/OD
 * TAB.METHYLPREDNISOLONE 32MG PO/OD
*  TAB.ATARAX;10MG OD [9 PM]
 * PHYSIOGEL LOTION L/A , BD*2 WEEKS .




Comments

Post a Comment

Popular posts from this blog

30 yrs old female

-
Image
  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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box 30 years old female presented to casualty with  chief complaints of sudden worsening of SOB since one day  History of presenting illness: patient was apparently normal till six years back in 2017 she had generalised body aches and joint pains which involves multiple large joints of which elbow And knee joints  troubled her associated with generalised body aches after multiple hospital visits  she even noticed hair loss without scarring and oral ulcers then she was diagnosed...
Read more

57yrs old male patient

-
Image
 ICU BED -2   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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box Chief complaints: C/o of constipation since 20 days  C/o  of fever since 4 to 5 days History of presenting illness:  patient came with c/o of constipation since 20 days I was admitted in hospital for three days  C/o of fever high-grade since 4 to 5 days more during night  history of hiccups 15 days back admitted in hospital for three days  no c/o of decreased urine output vomiting headache   chief complaints of decreased appetite since 5 to 6...
Read more

RishithaReddy

-
Image
 ONLINE BLENDED BIMONTHLY ASSESMENT-MAY I have been given the following cases 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 diagnosis and come up with a treatment plan. This is the link of the questions asked regarding the cases: http://medicinedepartment.blogspot.com/021/05/online-blended-bimonthly-assignment.html Below are my answers to the Medicine Assignment based on my comprehension of the cases.  1.Pulmonology A) https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html A 55 year old female patient, a resident of Miryalaguda and farmer by occupation  came to the hospital on 17/5/21  with the  chief complaints   of  shortness of breath, pedal edema  and  facial puffiness. 1) What is the evolution of the symptomatology in this patient in term...
Read more