13 yr old female


This is online E log book to discuss our patients health data shared after taking his guardians informed consent form

I have been given this case to solve in an attempt to understand topic of" patient clinical data analysis" to develop my competency in reading and comprehensing clinical data including history clinical findings
 investigations and come with a diagnosis and treatment plan. 

This is a case of 14 yr old female diagnosed with Sickle cell anaemia have multiple admissions for sickle cell crisis  now presented  with chief complaints of 
      - Joint pains more at night 
       - Right knee pain since 15 days 
       - left leg shin pain
HOPI
Patient was apparently asymptomatic 10 yrs back and diagnosed as Sicke cell anaemia
with known history of Abdominal pain, yellowish discoloration of eyes,SOB,fever,dry cough, pleural tap  and she had  blood transfusion 15 times since childhood and had multiple episodes of sickle cell crisis  and brochopneumonia  and pancreatitis for which she was admitted and treated.She was on her regular medication hydroxy urea 100 mg daily once .Now she presented with complaints of left  knee pain and right shin  and calcaneal region pain relieved on diclofenac i.m stat.

PAST HISTORY 
N/K/C/O DM,HTN,EPILEPSY
History of blood transfusions
She was having jaundice 2-3 yrs back with complaints of lower epigastric pain and SOB and occasional palpitations,for which she recieved 1 blood transfusion.

PERSONAL HISTORY
Appetite is normal
Mixed diet
Regular bowel and bladder movements
No known allergies

FAMILY HISTORY
No significant family history

GENERAL EXAMINATION
On examination pt is c/c/c
 well oriented with time and place .
Well nourished and built
No signs of 
 pallor ,cyanosis, lymphadenopathy,icterus,clubbing,edema of , Malnutrition, dehydration.

Temp:98.4F
Pulse rate: 86/ min
SpO2 : 98%
BP: 110/80 mm Hg
Hb: 8.6 

LIMB EXAMINATION
Left knee pain,Rt shin pain,
Normal skin 
No swelling 
No local rise of temp
No tenderness
SYSTEMIC EXAMINATION
 On examination pt is c/c/c
 Afebrile
CVS: S1,S2 +
L/S : BAE+ 

PROVISIONAL DIAGNOSIS
SICKLE CELL CRISIS

INVESTIGATIONS
ECG.       15/7/22

TREATMENT 
Inj.Diclofenac 1 amp for 24 hrs
1 PRBC Transfusion plan














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