General medicine case

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Chief complaint

A 13yr old female patient presented to the opd with chief complaint of abdominal pain since 2 days.

History of present illness:

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

2 episodes of vomiting since 2 days with food as content .

PAST HISTORY 

Pt is a known case of sickle cell anaemia since 2012 

History of sickle cell crisis 5 yrs ago

History of pancreatitis 2 yrs ago

Last blood transfusion  1 yr ago

PERSONAL HISTORY :

DIET - MIXED,

APPETITE -NORMAL ,

BOWEL MOVEMENT - REGULAR , 

BLADDER MOVEMENTS - REGULAR, 

ADDICTIONS(ALCOHOL AND SMOKING) - NO ADDICTIONS

FAMILY HISTORY - 

No family history 

Genral examination : 

PATIENT IS CONCIOUS , COHERENT COOPERATIVE

ICTRUS present, 

PALLOR present, 

No CLUBBING , CYANOSIS , LYMPHADENOPATHY, EDEMA

VITALS - 

TEMPERATURE - afibrile

PULSE RATE - 90 bpm

BLOOD PRESSURE - 110/70 mm of hg

RESPIRATORY RATE - 26cpm

SPO2 - 99 % AT ROOM AIR

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

IMMUNIZATION HISTORY

Patient is vaccinated according to National immunization schedule,

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

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 

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