13 YEAR OLD WITH GROSS HAEMATURIA AND ANASARCA

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 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-centred online learning portfolio and your valuable inputs on the 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 a diagnosis and treatment plan.
13Y/F presented to the opd with chief complaints of 
1) fever since 36 days
2) red coloured urine since 33 days 
3) pedal edema since 30 days
HOPI:
Patient was apparently asymptomatic 36 days ago , then developed fever which was low grade, intermittent type, relieved with medication not associated with chills & rigors . Vomitings 4 episodes /day for 3 days , content food particles, non bilious, non projectile. Loose stools 3-4 episodes/day, watery , not associated with abdominal pain, blood in stools .
Patient presented to the opd with complaints of hematuria since 33 days whole stream of urine red in colour. No burning micturition and frothiness of urine 
Then patient developed generalised swelling of body ,initially both lower limbs pedal edema then abdominal distension and facial puffiness.No h/o sore throat , decreased urinary output.
PAST HISTORY:
No history of similar complaints in the past

Not a k/c/o of DM, HTN, epilepsy, TB, CAD,CVD

PERSONAL HISTORY :

Appetite: Normal

Diet: Mixed

Sleep: adequate

Bowel and bladder: regular

Occupation: Student

MENSTRUAL HISTORY :

Attained menarche at 11 years

Regular cycles, flow is for 4 days , not associated with any pain and clots

LMP:27/11/22

FAMILY HISTORY:

No significant family history

GENERAL EXAMINATION:

Patient is conscious, cohorent ,cooperative and well oriented to time, place and person.

Pallor- present

Icterus- absent

Clubbing-absent

Lymphadenopathy- absent

Cyanosis- absent

Pedal edema - present (B/L)

VITALS: 

B.P:110/80 mmhg

P.R:86bpm

R.R: 16cpm

Temp:98.5F

SPO2: 99%@ RA

PER ABDOMEN:

Inspection- umbilicus inverted, all quadrants moving equally with respiration , no scars sinuses and engorged veins with visible pulsations

Palpation: soft , non tender

Auscultation: BS heard

CARDIOVASCULAR SYSTEM:

 on inspection : chest is elliptical bilaterally symmetrical 

Palpation: apex beat felt 

All inspectory findings confirmed

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes - 

Triceps  +2  +2

Biceps.  + 2  +2

Supinator +2  +2

Knee +2  +2

Ankle +2  +2

PROVISIONAL DIAGNOSIS:

POST INFECTIOUS GLOMERULONEPHRITIS ?SECONDARY TO ECOLI/SALMONELLA/STREPTOCOCCI

INVESTIGATIONS :

Fever chart :

URINE SAMPLE 

TREATMENT:

17/12/22

SALT AND FLUID RESTRICTION 

Vitals monitoring 4th Hrly

18/12/22

SALT AND FLUID RESTRICTION 

Vitals monitoring 4th Hrly

19/12/22

SALT AND FLUID RESTRICTION 

TAB LASIX 40mg PO/BD

Plan for renal biopsy

20/12/22

SALT AND FLUID RESTRICTION 

TAB LASIX 40mg PO/BD

Vitals monitoring 4th Hrly

Plan for renal biopsy today

21/12/22

SALT AND FLUID RESTRICTION 

TAB LASIX 40mg PO/BD

Vitals monitoring 4th Hrly

Plan for renal biopsy today

20 year old male with massive spleenomegaly

 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 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 comments 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 a diagnosis and treatment plan.

20 year male patient came to the casualty with the chief complaints of Neck pain since 2 days

                        Back pain since 2 days

                       Fever since 1 day

                       Blood in urine since 1 day(one episode)

HOPI:

Patient was apparently asymptomatic 2 days back then he developed neck pain which was of dragging type and insidious in onset and gradual in progression ,non radiating and relieved on medication( aceclofenac). It is not associated with vomitings, giddiness, rigidity and loss of consciousness. Back pain was in lower lumbar region and pricking type and was continuous. Fever was insidious in onset, low grade and relieved on medication.

Past history:

Patient had hypospadias and was corrected at 6 years of age.

Patient had facial puffiness and slight edema of lower and upper limbs at 12 years of age and was found to have anaemia and one unit of blood was transfused.

He had history of jaundice 10 days back

Not a known case of diabetes, hypertension, asthma, epilepsy, tb 

Family history: no similar complaints in family

Personal history:

Diet:mixed

He wakes up at 7:30 and eats rice and pickle for breakfast everyday . He takes dal and rice for lunch and curry and rice for dinner. Drinks tea in the evening.

Eats non veg twice a week.

Appetite: normal

Bowel and bladder movements: regular

Sleep :adequate(7-8 hrs)

No addictions

General examination 

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

Pallor present

Icterus present 

No cyanosis

No clubbing 

No lymphadenopathy 

No oedema

Vitals:

Temperature:98.7 F

Pulse rate: 98bpm

Respiratory rate:19cpm

Bp: 120/80 mmhg

Spo2: 98% on RA

Grbs:152mg/dl

Systemic examination 

Cvs:

S1 S2 present 

No thrills 

No murmurs 

Respiratory system:

Vesicular breath sounds 

Position of trachea is central 

No dyspnoea 

No wheeze 

Abdomen:

Shape of abdomen: scaphoid 

No tenderness 

No palpable masses 

No free fluids 

Spleen: palpable below left coastal margin 

Bowel sounds present 

CNS:

Patient is conscious 

Normal speech 

No neck stiffness 

Glasgow scale 15/15

Reflexes normal 

Investigations 

20/12/22

Hemogram (19/12/22)

Hb: 6.0

Total count: 2,500

RBC:20.6

Platelets: 1.54

Reticulocyte count:0.6%

Serum iron:34ug/dl

Serum electrolytes:

Sodium:132

Potassium :42

Chloride :102

Calcium:0.93

Blood urea:30

Serum creatinine:0.7

Lft:

Total bilirubin:2.51

Direct bilirubin:0.40

Sgot:24

Sgpt:19

Alp:158

Total proteins:6.7

Albumin:4.1

A/g ratio:1.63

LDH:110

Dengue NS1 antigen: negative

Blood for dengue test: IgM : reactive on (18/12/22)

Peripheral smear:

Microcytic hyprochromic anemia with leukopenia

Direct and indirect coombs test: negative

Ecg

Chest x ray

Usg abdomen and pelvis:

Massive spleenomegaly

Size:19.8 cms

Hemogram(20/12/22)

Hb:6.0

Total count:2,200

Rbc:3.82

Platelet count:1.24

Ferritin:5.1

                     X ray skull

X ray c spine

Hemogram (21/12/22)

Hemoglobin- 5.8gm/dl

Total count- 3,000cells/cmm

Neutrophils-40

Lymphocytes- 48

Eosinophils-02

Monocytes-10

Basophils-0

Rbc:3.63

Platelets-1.02 

Smear:

Anisopoikilocytosis with microcytes macrocytes ,normocytes,with few target cells and pencil forms.

Hemogram (22/12/22)

Hb:5.8

TLC:2,400

RBC:3.64

Platelet count:1.52

Hemogram (23/12/22)

Hb:5.8

TLC:2,300

Rbc:3.55

Platelet count:1.36

LFT(23/12/22)

Total bilirubin:1.20

Direct bilirubin:0.31

SGOT:20

SGPT:29

ALP:165

Total proteins:5.6

Albumin:3.4

A/G ratio:1.65

Hemoglobin electrophoresis:

Upper GI endoscopy:

Impression:

Atrophic fundal gastritis

Hemogram (24/12/22)

Hb:6.4

TLC: 3,000

Rbc:4.0

Platelet count:1.3

Bleeding time:2 mins 30 seconds

Clotting time:5 mins 00 seconds

APTT:40 seconds

PT:20 seconds

INR:1.4

LFT(24/12/22)

Total bilirubin:1.20

Direct bilirubin:0.31

Sgot:20

Sgpt:29

Alp:165

Total proteins: 5.6

Albumin:3.4

A/g ratio:1.65

Treatment:

19/12/22

Inj. Vitcofol 1500mcg IM/od

Tab hifenac p po bd

20/12/22

Inj. Vitcofol 1500 mcg im/od

Tab hifenac p po bd

Tab pan 40 mg po od

21/12/22

Inj. Vitcofol 1500mcg IM od

Tab hifenac p PO BD

Tab pan 40 mg po od

Inj FCM 500mg in 100ml ns /iv /stat 

Tab pcm 1 gm po sos

 

22/12/22

Inj. Vitcofol 1500mcg IM OD 

1 Ns @25ml/hr Iv

Inj iron sucrose 200 mg in 100 ml over 1 hr alternate days IV/OD

tab pcm 1gm po/bd

Tab. Pan 40mg po od

Tab. Buscopan po od 

23/12/22

Inj. Vitcofol 1500mcg IM OD 

1 Ns @25ml/hr Iv

Inj iron sucrose 200 mg in 100 ml over 2 hrs alternate days IV/OD

tab pcm 1gm po/bd

Tab. Pan 40mg po od

Tab. Buscopan po bd

24/12/22

Inj. Vitcofol 1500mcg IM OD 

1 Ns @25ml/hr Iv

Inj iron sucrose 200 mg in 100 ml over 2 hrs alternate days IV/OD

tab pcm 1gm po/bd

Tab. Pan 40mg po od

25/12/22

Bone marrow biopsy done yesterday 

Report awaiting 

Inj. Vitcofol 1500mcg /IM/OD ( day 6)

1 Ns @25 ml/hr Iv

Inj. IRON SUCROSE 200mg in 100ml over 2 hrs alternate days IV/od (dose 3)

Inj. Tramadol 1 ampoule in 100 ml NS sos

Tab pcm 1gm po sos(if temp. >101F)

Tab pan 40 mg po od

Vitals monitoring 4th hourly