Case of anemia

15 year old with ANEMIA
This is an online E logbook 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 an available global online community of experts to solve those patients 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 are welcome.

A 15 year male came to the opd with the following complaints.
CHIEF COMPLAINTS : 
Difficulty in micturition and burning sensation since 5 days.


HISTORY OF PRESENT ILLNESS
Patients was apparently asymptomatic 10 days back then he developed low grade fever which  is not associated with chills ,rigors and body pains.lasted for 5 days and relieved on medication. 

After the fever got subsided there is history of burning and difficulty in micturition since 5 days.
 And decreased urine output.Swelling of the area and pain was intermittent.
On further investigation patient was found to have low Hb levels .
No growth of the genitals and the hair in axilla , pubic hair.
No growth since 5 years.
H/O  of pica and decreased appetite
For fever he went to the hospital in nalgonda and the following investigations were performed





HISTORY OF PAST ILLNESS 
N/C/O of DM, HTN, TB ,ASTHMA, CAD

PERSONAL HISTORY
Decreased appetite , Vegetarian ,regular bowel movements ,  burning micturition , adequate sleep,no addictions

No significant drug history and family history

VITALS 
Bp 130/70 mmHg 
Pulse : 80 BPM
Afebrile temperature.

GENERAL EXAMINATION
Patient was conscious, coherent  and well oriented with time and place

Pallor -present 


No cyanosis
 No icterus 
No clubbing
Nolymphadenopathy 
No pedal edema
 Poorly built and nourished

CVS
S1,S2 are heard
No thrills and murmurs

RESPIRATORY SYSTEM 
Vesicular breath sound heard 

GENITAL DEVELOPMENT 
According to tanner scale chart it is stage 2 of development.

PROVISIONAL DIAGNOSIS
ANEMIA WITH GROWTH RETARDATION AND PHIMOSIS

INVESTIGATIONS:

USG: NO ABNORMALITY DETECTED
CBP: HB: 5.5mg/dl

Ferritin : 3.1ng/ml
Serum iron:38ug/dl

CUE : No abnormality detected
LFT : No abnormality detected



EARLY MORNING URINE SAMPLE.


 TREATMENT

5/09/22
1. Tab .DOLO 650 mg 
2. Tab.ZINCOVIT

6/09/22
1. Tab.DOLO 650mg
2.Inj.optineuron 1 amp in 100 ml
3. Syp.CITRALLKA 15 ml in glass of water

Same treatment followed on the following days.






Comments

Post a Comment

Popular posts from this blog

OSCE PREFINAL EXAMINATION

Image
Date :1/12/ 2023 Case blog: http://vasavipakker.blogspot.com/2023/11/female-with-break-bone-fever.html 25 yr old female housewife by occupation  resident of nalgonda came to general medicine OPD with  Chief complaints:- Body pains since 6 days Fever since 3 days On examination: Hess test positive . NS 1 antigen detected PROVISIONAL DIAGNOSIS:   Dengue fever LINK: http://vasavipakker.blogspot.com/2023/11/female-with-break-bone-fever.html WHAT ARE THE NEWER MODALITIES FOR TREATING DENGUE?? DOXYCYCLINE link:https://journals.lww.com/jfmpc/fulltext/2022/06000/effect_of_doxycycline_and_doxycycline_with_carica.161.aspx#:~:text=The%20study%20results%20indicate%20that,and%20to%20minimize%20hospital%20stay Doxycycline is a derivative of tetracycline that possesses broad antimicrobial and antiinflammatory activities. Further, antiviral activity of doxycycline has been reported against retroviruses, and a significant reduction in retrovirus titre was observed after incubation of infected cells wit
Read more

Vasavi 100

  BIOMONTHLY ASSIGNMENT -JUNE 2021 This is a bio monthly blended assignment of general medicine regarding the cases presented in the month of june . The assignment is the review of the cases . QUESTION 1 competency tested for peer review  https://amishajaiswal03eloggm.blogspot.com/ PULMONOLOGY Case 1:https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html Review: This is a case of a 55 yr old female patient with provisional diagnosis of acute exacerbation of COPD associated with heart failure and brochiectasis. The patient came with the chief complaints of shortness of breath , pedal edema and facial puffiness. she also has the history of type 1 diabetes mellitus and hypertension. The presentation of the investigation  regarding the diagnosis were presented in an order. The anatomical localization of the problem is at the brochioles due to exposure to dust or allergens in the paddy feilds.  NEUROLOGY Case 2:https://143vibhahegde.blogspot.com/2021
Read more

facial puffiness and edema of limbs

Image
This is an online E logbook 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 an available global online community of experts to solve those patients 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 are welcome. a 53-year-old male, a Hotel owner and chief by occupation, The patient presented to the hospital with chief complaints of Swelling of both Legs since 10 days Swelling of face since 7 days HISTORY OF PRESENTING ILLNESS   The patient was apparently asymptomatic 10 days ago.In the first week of June he had a binge of alcohol on occasion of local festival. Later he observed abdominal distension, followed by Bilateral Pedal odema which is pitting type extending up to the knee, insidious in gradually pr
Read more