Short case

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Chief complaint:

A 13 year old female came to OPD with complaints of abdominal pain since 2 days 

HISTORY OF PRESENTING ILLNESS -

Patient was apparently asymptomatic 2 days ago then develop epigastric pain on radiating moderate severity and gradually progressive.

PAST HISTORY 


Pt is a known case of sickle cell anaemia since 2012 

History of sickle cell crisis 2016

History of pancreatitis 2019

Last blood transfusion 2020


PERSONAL HISTORY :


DIET - MIXED,

APPETITE -NORMAL ,

BOWEL MOVEMENT - REGULAR , 

BLADDER MOVEMENTS - REGULAR, 

ADDICTIONS(ALCOHOL AND SMOKING) - NO ADDICTIONS


FAMILY HISTORY - 

No family history


TREATMENT HISTORY

patient is currently on

T. Hydroxyurea 1000mg po OD

T. Benzylpenicillin 600 mg po OD

T. Sodamint TID

T. Folate 5mg po OD

T. Calcium 500mg po OD

T. Zincovit po od

T. Liv 52 OD


IMMUNIZATION HISTORY

Patient is vaccinated according to National immunization schedule,

Pneumococcal, typhoid, hepatitis vaccine taken on 23/1/22



ON EXAMINATION -


PATIENT IS CONSCIOUS , COHERENT COOPERATIVE

ICTERUS present, 

PALLOR present, 

No CLUBBING , CYANOSIS , LYMPHADENOPATHY, EDEMA


VITALS - 

TEMPERATURE - 97' F

PULSE RATE - 90 BPM

BLOOD PRESSURE - 110/70 MM OF HG 

RESPIRATORY RATE - 26 BPM

SPO2 - 99 % AT ROOM AIR

HT - 144 cm

WT - 36 kg


SYSTEMIC EXAMINATION - 


CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

CENTRAL NERVOUS SYSTEM : NAD

P/A - diffuse tenderness present, no organomegaly

INVESTIGATIONS:

Serum lipase #570 IU/L (13- 60)

Serum creatinine #0.4 mg/dl (0.5 -1)



SERUM ELECTROLYTES

Sodium 140 mEq/L

Potassium 4.2 mEq/L

Chloride 101 mEq/L 


Blood urea :46 mg/ dl(12-42)


Blood investigations:

HB #7.9 gm /dl(12-15)

Total count #16,400 cell/cumm(4000-10000)

Neutrophils 75 %(40-80)

Lymphocyte #17%(20-40)

MCHC #37.6 % (31.5 -34.5)

RBC count # 2.50 millions per cumm( 3.8-4.8)



LIVER FUNCTION TESTS

Total bilirubin #20.5qmg/dl(0-1)

Direct bilirubin #14.13mg/dl(0.0-0.2)

SGOT #170 IU/L(0-31)

SGPT #180 IU/L (0-34)


Alkaline phosphatase #566(54-369)


Serum amylase #944 IU/L ( 25-140)

Blood urea 13 mg/dl

LDH  #543 IU/L (230 -460)



BLOOD GROUPING

O+VE






COLOUR DOPPLER 2D ECHO


USG ABDOMEN





Clinical images:










Provisional diagnosis:
Pain abdomen secondary to acute pancreatitis, known case of sickle cell anaemia

Treatment:

IVF NS/DNS AT 75 ML/HR

INJ. PAN 40 MG IV OD

INJ. OPTINEURON 1 AMP IN 100 ML NS OVER 30 MINS

INJ. TRAMADOL 1 AMP IN 100 ML NS OVER 30 MINS


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