14F Sickle Cell Tibial Pain Telangana PaJR
le cell crisis CBBLE UDHC similar cases
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 AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
ULTRA SOUND ABDOMEN
USG ABDOMEN
On 15-11-2024.
PPM 2 - 5 pm today.
PPM 1 - How's she subjectively today?
On 18-11-2024
No C/O fever since yesterday evening. Apetite improved. Spo2 on room air: 91-92.
Subjectively feels better. One fever spikes at 7 am today- 100.5F
Fever spikes present.
February 1 2022
A 13 year old female came to OPD with complaints of abdominal pain since 2 days associated with two episodes of vomitings
HISTORY OF PRESENTING ILLNESS -
Patient was apparently asymptomatic 2 days ago then develop epigastric pain on radiating moderate severity and gradually progressive, non radiating
2 episodes of vomiting since 2 days with food as content and non bilious non projectile no relation to feeds
PAST HISTORY -
K/C/O OF sickle cell anaemia since 2012
history of recurrent Bronchopneumonia 5 episodes,
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 -
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 CONCIOUS , COHERENT COOPERATIVE
ICTRUS 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
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
NO SONOLOGIC ABNORMALITIES DETECTED
TREATMENT PLAN
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
Clinical images
SOAP NOTES DAY 1, 8PM
S:
PAIN ABDOMEN SUBSIDED
SOB decreased
No fever spikes
O
ON EXAMINATION -
PATIENT IS CONCIOUS , COHERENT
GCS 15
ICTERUS present,
PALLOR present,
No CLUBBING , CYANOSIS , LYMPHADENOPATHY, EDEMA
VITALS -
TEMPERATURE - 98' F
PULSE RATE - 96 BPM
BLOOD PRESSURE - 110/80 MM OF HG
RESPIRATORY RATE - 26
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
A
Pain abdomen secondary to acute pancreatitis, known case of sickle cell anaemia
P
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
SOAP NOTES DAY 2
13/F
Day 2
S:
PAIN ABDOMEN SUBSIDED
SOB decreased
No fever spikes
O
ON EXAMINATION -
PATIENT IS CONCIOUS , COHERENT
GCS 15
ICTERUS present,
PALLOR present,
No CLUBBING , CYANOSIS , LYMPHADENOPATHY, EDEMA
VITALS -
TEMPERATURE - 98' F
PULSE RATE - 96 BPM
BLOOD PRESSURE - 110/70 MM OF HG
RESPIRATORY RATE - 26
SPO2 - 92% AT ROOM AIR,requiring 3to 4 litres of oxygen
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
A
Pain abdomen secondary to acute pancreatitis, known case of sickle cell anaemia
P
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
LFT
TB- 10.06
DB-5.9
AST-101
ALT-102
ALP-488
TP-6.5
ALB-3.7
HEMOGRAM
HB-7.2
TLC-22900
PCV-19.8
MCV-84.6
MCH-31.2
PLT-4.04
Normochromic, normocytic, sickle cells, target cells, fragmented cells
SOAP NOTES DAY 3
S - complaint of pain abdomen resolving, 1 episode of fever at 4-AM TODAY, and dry chough
O -
Ictrus still +,
PR 120,
spo2 86%on RA,
oxygen support tappered to 4 FROM 6,
SPO2 98% WITH 4L O2
BP 100/60mmhg
A - pain abd 2 to pancreatitis ( secondary to microlithiasis/ischemic pancreatitis)
P- endoscopy, oxygen support
Inj. Diclofenac 75 mg IV SOS
Inj. TRAMADOL 1 AMP in 100 ML NS IV SOS
T. Montekh LC BD
SYP. Ascoril-D 10ml TID
CXR day 3
1- bulky pancreas
2- cholelithiasis
3- RT basal lung consolidated, with pleural effusion
ABG 11 AM
Day 4
Day 4 morning
Young GIRL with sickle cell anaemia and pancreatitis
S - complaint of SOB, 1 episode of fever at 6-AM TODAY
O -
Ictrus still +,
PR 132,
spo2 76%on RA,
SPO2 98% WITH 4L O2
BP 100/60mmhg
Temp - 101' F
RR - 21
CVS - S1S2 +
RS - DECREASED BREATH SOUNDS RT IAA, IMA, SSA
PA soft, non-tender
Chest x-ray - rt pleural effusion, rt lower lobe consolidation
A - PANCREATITIS SECONDARY TO cholelithiasis, Rt lower lobe consolidation secondary to acute chest syndrome or pneumonia
P- endoscopy, oxygen support
Inj. Augmentin 650m IV BD
T. Azithromycin 500mg PO OD
Inj. Diclofenac 75 mg IV SOS
Inj. TRAMADOL 1 AMP in 100 ML NS IV SOS
T. Montekh LC BD
SYP. Ascoril-D 10ml TID
SARS-COV-2 - negative
Chest x-ray
ABG with 4L O2 NIV
HEMOGRAM
RFT
Urea 18
Creatinine 0.6
Na 141
K 4.2
Cl 97
S. Amylase
97
S. LDH
PLEURAL FLUID ANALYSIS
SOAP NOTES DAY 5
AMC :
Day 5 morning
Young GIRL with sickle cell anaemia and pancreatitis and acute chest syndrome
S - complaint of SOB (DECREASED)
O -
Ictrus still +,
PR 92,
spo2 80%on RA,
SPO2 98% WITH INTERMITTENT CPAP 6L O2
BP 100/60mmhg
Temp - 99.5' F
RR - 21
CVS - S1S2 +
RS - DECREASED BREATH SOUNDS RT IAA, IMA, SSA
PA soft, non-tender
1 unit PRBC TRANSFUSION DONE YESTERDAY
Total protein 6.2
S. Amylase 97
Pf protein 3.2
Pf. LDH 340
S. LDH 388
Pf. Amylase 75
Pf cytology 140 cells
Light's criteria
Pf. Protein/ S. Protein = 0.51
Pf. LDH/S. LDH = 0.87
Pf. LDH 340 > 2/3 UL S. LDH(360)
Exudative effusion
A -
k/c/o sickle cell anemia.
R lower lobe consolidation secondary to pneumonia/? Acute chest syndrome.
Acute pancreatitis secondary to ?cholelithiasis/Vaso-occlusive crisis.
P- oxygen support
Inj. PAN 40MG IV OD
Inj. Piptaz 2.25g IV QID
Inj. Diclofenac 75 mg IV SOS
Inj. Levofloxacin 500mg IV OD
T. Hydroxyurea 1000mg PO OD
T. Montekh LC BD
SYP. Ascoril-D 10ml TID
One more prbc transfusion today
LFT
HEMOGRAM
SOAP NOTES DAY 6
S - complaint of SOB (DECREASED)
O -
Ictrus still +,
PR 92,
spo2 80%on RA,
SPO2 98% WITH INTERMITTENT CPAP 6L O2
BP 100/60mmhg
Temp - 99.5' F
RR - 21
CVS - S1S2 +
RS - DECREASED BREATH SOUNDS RT IAA, IMA, SSA
PA soft, non-tender
1 unit PRBC TRANSFUSION DONE YESTERDAY
Total protein 6.2
S. Amylase 97
Pf protein 3.2
Pf. LDH 340
S. LDH 388
Pf. Amylase 75
Pf cytology 140 cells
Light's criteria
Pf. Protein/ S. Protein = 0.51
Pf. LDH/S. LDH = 0.87
Pf. LDH 340 > 2/3 UL S. LDH(360)
Exudative effusion
A -
k/c/o sickle cell anemia.
R lower lobe consolidation secondary to pneumonia/? Acute chest syndrome.
Acute pancreatitis secondary to ?cholelithiasis/Vaso-occlusive crisis.
P- oxygen support
Inj. PAN 40MG IV OD
Inj. Piptaz 2.25g IV QID
Inj. Diclofenac 75 mg IV SOS
Inj. Levofloxacin 500mg IV OD
T. Hydroxyurea 1000mg PO OD
T. Montekh LC BD
SYP. Ascoril-D 10ml TID
One more prbc transfusion today
SOAP NOTES DAY 7
ICU :
Day 7 morning
Young GIRL with sickle cell anaemia and pancreatitis and acute chest syndrome
S - complaint of SOB (DECREASED)
O -
Ictrus still +,
PR 92,
spo2 80%on RA,
SPO2 98% WITH INTERMITTENT CPAP 6L O2
BP 100/60mmhg
Temp - 98.5' F
RR - 27
CVS - S1S2 +
RS - DECREASED BREATH SOUNDS RT IAA, IMA, SSA
PA soft, non-tender
LFT
TB - 3.61
DB - 1.21
AST - 42
ALT - 46
ALP - 268
TP - 6.6
ALB - 3.63
HEMOGRAM
Chest X-ray
A -
k/c/o sickle cell anemia.
R lower lobe consolidation secondary to pneumonia/? Acute chest syndrome.
Acute pancreatitis secondary to ?cholelithiasis/Vaso-occlusive crisis.
P- oxygen support
Inj. PAN 40MG IV OD
Inj. Piptaz 2.25g IV QID
Inj. Diclofenac 75 mg IV SOS
Inj. Levofloxacin 500mg IV OD
T. Hydroxyurea 1000mg PO OD
T. Montekh LC BD
SYP. Ascoril-D 10ml TID
One more prbc transfusion today
SOAP NOTES DAY 8
AMC :
Day 7 morning
Young GIRL with sickle cell anaemia and pancreatitis and acute chest syndrome
S - complaint of SOB (DECREASED)
O -
Ictrus still +,
PR 92,
spo2 80%on RA,
SPO2 98% WITH INTERMITTENT CPAP 6L O2
BP 100/60mmhg
Temp - 98.5' F
RR - 27
CVS - S1S2 +
RS - DECREASED BREATH SOUNDS RT IAA, IMA, SSA
PA soft, non-tender
A -
k/c/o sickle cell anemia.
R lower lobe consolidation secondary to pneumonia/? Acute chest syndrome.
Acute pancreatitis secondary to ?cholelithiasis/Vaso-occlusive crisis.
P- oxygen support
Inj. PAN 40MG IV OD
Inj. Piptaz 2.25g IV QID
Inj. Diclofenac 75 mg IV SOS
Inj. Levofloxacin 500mg IV OD
T. Hydroxyurea 1000mg PO OD
T. Montekh LC BD
SYP. Ascoril-D 10ml TID
HEMOGRAM
SOAP NOTES DAY 9
AMC :
Day 9 morning
Young GIRL with sickle cell anaemia and pancreatitis and acute chest syndrome
S - complaint of SOB (DECREASED)
O -
Ictrus absent,
PR 92,
spo2 95%on RA,
SPO2 100% WITH 4L O2
BP 110/80mmhg
Temp - 98.5' F
RR - 23
CVS - S1S2 +
RS - DECREASED BREATH SOUNDS RT IAA, SSA
PA soft, non-tender
LFT
TB - 3.38
DB - 1.09
AST - 28
ALT - 39
ALP - 260
TP - 6.7
ALB - 3.5
CBP
HB - 9.1
TLC - 17,700
Plt - 5.57
A -
k/c/o sickle cell anemia.
R lower lobe consolidation secondary to pneumonia/? Acute chest syndrome.
Acute pancreatitis secondary to ?cholelithiasis/Vaso-occlusive crisis.
P-
oxygen support
Inj. PAN 40MG IV OD
Inj. Piptaz 2.25g IV QID day 5
Inj. Levofloxacin 500mg IV OD day 5
T. Hydroxyurea 1000mg PO OD
SOAP NOTES DAY 10
Ward :
Day 10 morning
S - complaint of SOB (DECREASED)
O -
Ictrus absent,
PR 97,
spo2 95%on RA,
BP 110/80mmhg
Temp - 98.3' F
RR - 23
CVS - S1S2 +
RS - DECREASED BREATH SOUNDS RT SSA
PA soft, non-tender
A -
k/c/o sickle cell anemia.
R lower lobe consolidation secondary to pneumonia/? Acute chest syndrome.
Acute pancreatitis secondary to ?cholelithiasis/Vaso-occlusive crisis.
P-
Inj. PAN 40MG IV OD
Inj. Optineuron 1 AMP in 100 ML NS IV OD
T. Hydroxyurea 1000mg PO OD
15-11-2024
PPM 1 - How is the patient today?
PPM 2 - She is in OP. Lower back and right kne pain since 2 days. Admitting her sir.
PPM 1 -👍 Share her previous discharge summaries.
PPM 2 - Okay sir. She also has all the previous discharge summaries with her now
. : 15 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 17/12/2019 07:36 PM
Name of Treating Faculty
Pediatrics
Diagnosis
K/C/O SICKLE CELL ANEMIA ? VASOOCCLUSIVE CRISIS WTH ACUTE PANCREATITIS
Case History and Clinical Findings
8Y OLD FEMALE CHILD, KNOWN CASE OF SICKLE CELL ANEMIA, BROUGHT WITH C/O PAIN ABDOMEN ON AND OFF SINCE 1 MONTH IN EPIGASTRIC REGION, LEFT HYPOCHONDRIUM, RADIATING TO LEFT SUBSCAPULAR REGION, ON AND OFF, RELEIVED ON MEDICATION. C/O VOMITINGS, 5EPISODES SINCE TODAY AFTERNOON, CONTENTS FOOD/WATERY, BILIOUS VOMITING, NON PROJECTILE, NO RELATION TO FEEDS.
PAST HISTORY- K/C/O SICKLE CELL ANEMIA SINCE 2012.H/O 7PICU ADMISSIONS IN PAST I/V/O BRONCHOPNEUMONIA. H/O 1PICU ADMISSION IN NILOUFER ON 23/10/18 WITH 7DAYS HOSPITAL STAY AND 2PINTS BLOOD TRANSFUSION DONE(HB-6.7).
ANTENATAL HISTORY- UNEVENTFUL( 1PINT BLOOD TRANSFUSION DONE TO MOTHER AFTER DELIVERYY)
NATAL HISTORY-UNEVETFUL. POSTNATAL HISTORY-UNEVETFUL.
IMMUNISATION HISTORY:BCG SCAR+,AS PER SCHEDULE DEVELOPMENTAL HISTORY:AS PER AGE
ON EXAMINATION:CHILD IS CONSIOUS,AWAKE,NO PALLOR/ICTERUS/CYANOSIS,ALL PULSES FELT-NORMAL
VITALS:TEMPERATURE-99.4F,RR-19,PR-104,SPO2 -99%@RA,BP-100/70 ANTHROPOMETRY- HT-137CM, WT-27KG, BMI-14.4
HEAD TO TOE-NORMAL SYSTEMIC EXAMINATION:
PER ABDOMEN:SHAPE OF THE ABDOMEN-NORMAL,UMBILICUS-NORMAL,NO SCARS/SINUSES/DIALTED VEINS,ON PALPATION ABDOMEN IS SOFT,TENDERNESS PRESENT, LIVER PALPABLE 1CM, BOWEL SOUNDS+
RESPIRATORY SYSTEM:SHAPE OF THE CHEST-NORMAL,TRACHEA APPEARS CENTRAL,B/L EQUAL EXPANSION OF CHEST,NO SCRAS/SINUSES/DILATED VEINS,BAE+,NVBS+,LUNGS CLEAR
CVS:SHAPE OF THE CHEST-NORMAL,NO SCARS/SINUSES/PRECORDIAL BULGE,APEX BEAT FELT AT 4TH ICS,S1S2+,NO MURMURS
CNS:NAD
AT THE TIME OF DISCHARGE PATIENT IS HEMODYNAMICALLY STABLE AND FIT FOR DISCHARGE.
VITALS - TEMPERATURE-99.4F,RR-19,PR-104,SPO2 -99%@RA,BP-100/70 SE- RS-NVBS, CVS-S1 S2+, PA-SOFT,NT, CNS-NAD
Investigation
17/12/19- S.AMYALSE-459, S.LIPASE-144
19/12/19- S.AMYALSE-46, S.LIPASE-18 HEMOGRAM-
17/12/19-HB-8.6, TLC-18100, PCV-23.4, PLT-4.58
21/12/19-HB-10.1, TLC-8400, PCV-28.6, PLT-1.2 RETICULOCYTE COUNT-1%
HIV-NEGATIVE, HBSA-NEGATIVE
CRP-NEGATIVEDENGUE-NEGATIVE BGT=O POSITIVE
S.FERITINE-271, S.IRON-61, S.LDH-352 ESR-25
PT-15, INR-1.11, APTT-31, BT-5MIN, CT-2MIN30SEC
CUE-CLOUDY, TRACE ALBUMIN, SUGARS-NIL, PUS CELLS-6-8, EPITELIAM-3-4, RBC-1-2. URINE FOR BILE SALT-NEGATIVE
URINE FOR BILE PIGMENTS-NEGATIVE
PEDIATRIC SURGERY OPINION TAKEN,SUGGESTED NBM AND OCTREOTIDE FOR 7 DAYS CECT ABDOMEN- ACUTE EDEMATOUS PANCREATITIS(MODIFIED CT SEVEARITY INDEX- 6/10), HYPERDENCE SLUDGE IN THE GALL BLADDER.
Investigations
Name Value Range Name Value Range
RFT 17-12-2019 07:58:PM LIVER FUNCTION TEST (LFT) 17-12-2019 07:58:PM
UREA 14 mg/dl 42-12 mg/dl Total Bilurubin 4.93 mg/dl 1-0 mg/dl
CREATININE 1.4 mg/dl 1-0.5 mg/dl Direct Bilurubin 1.63 mg/dl 0.2-0.0 mg/dl
URIC ACID 3.9 mmol/L 6-2.6 mmol/L SGOT(AST) 134 IU/L 31-0 IU/L
CALCIUM 10.2 mg/dl 10.2-8.6 mg/dl SGPT(ALT) 100 IU/L 34-0 IU/L
PHOSPHOROUS
SODIUM 4.4 mg/dl
140 mmol/L 4.5-2.5 mg/dl
145-136 mmol/L ALKALINE PHOSPHATASE 401 IU/L 369-54 IU/L
POTASSIUM 4.2 mmol/L. 5.1-3.5 mmol/L. TOTAL PROTEINS 7.2 gm/dl 8-6 gm/dl
CHLORIDE 105 mmol/L 98-107 mmol/L ALBUMIN 4.2 gm/dl 4.5-3.2 gm/dl
A/G RATIO 1.44
PERIPHERAL RBC : Normocytic HBsAg-RAPID 17- Negative Kit Name :
SMEAR 17-12-2019 normochromic anemia 12-2019 08:02:PM Life Band
07:58:PM WBC : increased in
count PLATELET :
Adequate
SERUM 357 IU/L 140-25 IU/L LIVER FUNCTION TEST (LFT) 19-12-2019 12:57:PM
AMYLASE 17-12- Total Bilurubin 1.52 mg/dl 1-0 mg/dl
2019 09:35:PM Direct Bilurubin 0.89 mg/dl 0.2-0.0 mg/dl
SGOT(AST) 34 IU/L 31-0 IU/L
SGPT(ALT) 38 IU/L 34-0 IU/L
ALKALINE 263 IU/L 369-54 IU/L
PHOSPHATASE
TOTAL PROTEINS 5.9 gm/dl 8-6 gm/dl
ALBUMIN 3.6 gm/dl 4.5-3.2 gm/dl
A/G RATIO 1.54
SERUM 46 IU/L
AMYLASE 19-12-
2019 12:57:PM 140-25 IU/L
Treatment Given(Enter only Generic Name)
NBM FOR 2 DAYS
IVF HALF DNS @45ML/HR FOR 2DAYS INJ.PIPTAZ(100MG/KG/DOSE) 2.7G/IV/TID FOR 5 DAYS INJ.PANTOP (1MG/KG/DOSE)2.7CC+2CC NS/IV/BD FOR 5 DAYS INJ.ZOFER(0.2MG/KG/DOSE)2.7CC+2CC NS/IV/TID TAB.HYDROXYUREA 500MG/PO/OD
TAB.COMBIFLAM 1TAB/PO/TID
TAB.PENTID(PENCILLIN G POTASSIUM TAB)400MG/PO/OD TAB.FOLVITE 5MG/PO/OD
INJ.OCTREOTIDE 30MCG/KG/DOSE FOR 7 DAYS
ONE BLOOD TRANSFUSION DONE.TRANSFUSION WAS UNEVENTFUL
Advice at Discharge
TAB HYDROXYUREA 50MG/PO/OD TAB FLOVITE 5MG/PO/OD
REVIEW AT PEDIATRIC OPD AFTER 13 DAYS ALONG WITH USG ABDOMEN 6/1/2020
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Age/Gender : 15 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 21/03/2020 07:36 AM
Name of Treating Faculty
DR SURESH THOMAS
Diagnosis
K/C/O SICKLE CELL ANAEMIA WITH PANCREATITIS
Case History and Clinical Findings
hopi:11 year old female child was brought for regular follow up which is a k/c/o sickle cell disease with acute pancreatitis
past h/o:k/c/o sickle cell anaemia since 2012
h/o picu admission in kims for bronchopneumonia with acute pancreatitis and also admission in nims and niloufer where patient received blood tranfusion 12 times
h/o icterus (jaundice) and abdominal pain over epigastric region since 7months which is on and off. antenatal h/o;uneventful
natal h/o: uneventful immunization h/o:as per the age developmental h/o:as per the age
family h/o:parents are sickle cell trait positive general examination:
vitals: temp:99 f hr:102/min rr:22/min spo2:99% bp:100/70 min
anthropometry: weight:27 kgs
height:137cm bmi:14.4
systemic examination:
p/a: soft,non tender ,no organomegaly rs:bae+nvbs, lungs clear
cvs:s1s2 heard,no murmurs cns:nad
Treatment Given(Enter only Generic Name) 1.Tab.hydroxyurea (1 tab 500mg) @1 tab/po/od 2.Tab.pentid (1tab= 400mg) 1 tab/po/od 3.Tab.sodamint 3 tabs/po/tid
4.Tab.folvite (1 tab 5 mg) @ 1 tab/po/od 5.Tab.shelcal 500mg 1/2 tab /po/od 6.Tab.zincovit 1 tab/po/od
Advice at Discharge 1.Tab.hydroxyine 1 tab/po/od 2.Tab.pentid 400mg 1 tab/po/od 3.Tab.sodamint 3 tabs/po/tid
4.Tab.folvite 5 mg 1 tab/po/od 5.Tab.shelcal 500mg1/2 tab /po/od 6.Tab.zincovit 1 tab/po/od
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date
Date: Ward: Unit:
Age/Gender : 15 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 17/02/2020 08:47 PM
Name of Treating Faculty
DR.SURESH THOMAS
Diagnosis
K/C/O SICKLE CELL ANAEMIA WITH PANCREATITIS
Case History and Clinical Findings
hopi:11 year old female child was brought for regular follow up which is a k/c/o sickle cell disease with acute pancreatitis
past h/o:k/c/o sickle cell anaemia since 2012
h/o picu admission in kims for bronchopneumonia with acute pancreatitis and also admission in nims and niloufer where patient received blood tranfusion 12 times
h/o icterus (jaundice) and abdominal pain over epigastric region since 7months which is on and off. antenatal h/o;uneventful
natal h/o: uneventful immunization h/o:as per the age developmental h/o:as per the age
family h/o:parents are sickle cell trait positive general examination:
vitals: temp:99 f hr:102/min rr:22/min spo2:99% bp:100/70 min
anthropometry: weight:27 kgs
height:137cm bmi:14.4
systemic examination:
p/a: soft,non tender ,no organomegaly rs:bae+nvbs, lungs clear
cvs:s1s2 heard,no murmurs cns:nad
Investigation
NameValueRangeNameValueRangeRFT 17-02-2020 10:31:PM UREA13 mg/dl30-10 mg/dlCREATININE0.5 mg/dl0.7-0.3 mg/dlURIC ACID5.4 mg/dl5-2 mg/dlCALCIUM10.1 mg/dl10.2-8.6 mg/dlPHOSPHOROUS4.6 mg/dl7-4 mg/dlSODIUM137 mEq/L145-138 mEq/LPOTASSIUM4.2 mEq/L4.7-3.4 mEq/LCHLORIDE103 mEq/L98-107 mEq/LLIVER FUNCTION TEST (LFT) 17-02-2020
10:31:PM Total Bilurubin2.71 mg/dl1-0 mg/dlDirect Bilurubin0.97 mg/dl0.2-0.0 mg/dlSGOT(AST)43 IU/L31-0 IU/LSGPT(ALT)20 IU/L34-0 IU/LALKALINE PHOSPHATE315 IU/L369-54 IU/LTOTAL
PROTEINS6.9 gm/dl8-6 gm/dlALBUMIN4.17 gm/dl5.4-3.8 gm/dlA/G RATIO1.53
Investigations
Name Value Range Name Value Range
PERIPHERAL RBC : Normocytic SMEAR 17-02-2020 normochromic anemia 10:31:PM WBC : leucocytosis
PLATELET : Adequate RFT 17-02-2020 10:31:PM
UREA 13 mg/dl 42-12 mg/dl
CREATININE 0.5 mg/dl 1-0.5 mg/dl
URIC ACID 5.4 mmol/L 6-2.6 mmol/L
CALCIUM 10.1 mg/dl 10.2-8.6 mg/dl
PHOSPHOROUS 4.6 mg/dl 4.5-2.5 mg/dl
SODIUM 137 mmol/L 145-136 mmol/L
POTASSIUM 4.2 mmol/L. 5.1-3.5 mmol/L.
CHLORIDE 103 mmol/L 98-107 mmol/L
LIVER FUNCTION TEST (LFT) 17-02-2020 10:31:PM
Total Bilurubin 2.71 mg/dl 1-0 mg/dl
Direct Bilurubin 0.97 mg/dl 0.2-0.0 mg/dl
SGOT(AST) 43 IU/L 31-0 IU/L
SGPT(ALT) 20 IU/L 34-0 IU/L
ALKALINE 315 IU/L 369-54 IU/L PHOSPHATASE
TOTAL PROTEINS 6.9 gm/dl 8-6 gm/dl
ALBUMIN 4.17 gm/dl 4.5-3.2 gm/dl
A/G RATIO 1.53
Treatment Given(Enter only Generic Name) 1.Tab.hydroxyurea (1 tab 500mg) @1 tab/po/od 2.Tab.pentid (1tab= 400mg) 1 tab/po/od
3. Tab.sodamint 3 tabs/po/tid
4. Tab.folvite (1 tab 5 mg) @ 1 tab/po/od 5.Tab.shelcal 500mg 1/2 tab /po/od 6.Tab.zincovit 1 tab/po/od
Advice at Discharge 1.Tab.hydroxyine 1 tab/po/od 2.Tab.pentid 400mg 1 tab/po/od 3.Tab.sodamint 3 tabs/po/tid
4.Tab.folvite 5 mg 1 tab/po/od 5.Tab.shelcal 500mg1/2 tab /po/od 6.Tab.zincovit 1 tab/po/od
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Age/Gender : 15 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 01/02/2022 11:26 AM
Name of Treating Faculty
Medicine
Case History and Clinical Findings
A 13 year old female came to OPD with complaints of abdominal pain since 2 days associated with two episodes of vomitingsPatient was apparently asymptomatic 2 days ago then develop epigastric pain on radiating moderate severity and gradually progressive, non radiating2 episodes of vomiting since 2 days with food as content and non bilious non projectile no relation to feedsPAST HISTORY - K/C/O OF sickle cell anaemia since 2012history of recurrent Bronchopneumonia 5 episodes,History of sickle cell crisis 2016History of pancreatitis 2019Last blood transfusion 2020PERSONAL HISTORY :DIET - MIXED,APPETITE -NORMAL ,BOWEL MOVEMENT - REGULAR ,BLADDER MOVEMENTS - REGULAR, ADDICTIONS(ALCOHOL AND SMOKING) - NO
ADDICTIONSTREATMENT HISTORYpatient is currently onT. Hydroxyurea 1000mg po ODT. Benzylpenicillin 600 mg po ODT. Sodamint TIDT. Folate 5mg po ODT. Calcium 500mg po ODT. Zincovit po odT. Liv 52 ODIMMUNIZATION HISTORYPatient is vaccinated according to National immunization schedule,Pneumococcal, typhoid, hepatitis vaccine taken on 23/1/22ON EXAMINATION -PATIENT IS CONCIOUS , COHERENT COOPERATIVEICTRUS present,PALLOR present,No CLUBBING , CYANOSIS , LYMPHADENOPATHY, EDEMAVITALS -TEMPERATURE - 97' FPULSE RATE - 90 BPMBLOOD PRESSURE - 110/70 MM OF HGRESPIRATORY RATE -
26SPO2 - 99 % AT ROOM AIRHT - 144 cmWT - 36 kgSYSTEMIC EXAMINATION - CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURSRESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDSCENTRAL
NERVOUS SYSTEM : NADP/A - diffuse tenderness present, no organomegaly
Investigation
ULTRA SOUND ABDOMENNO SONOLOGIC ABNORMALITIES DETECTED
Treatment Given(Enter only Generic Name)
1)IVF NS/DNS AT 75 ML/HR2)INJ. PAN 40 MG IV OD3)INJ. OPTINEURON 1 AMP IN 100 ML NS OVER 30 MINS4)INJ. TRAMADOL 1 AMP IN 100 ML NS OVER 30 MINS
Advice at Discharge
1) TAB. CEFIXIME 200 MG PO/OD
2) TAB. LEVOFLOXACIN 500 MG PO/OD
Follow Up
REVIEW SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date
Date:09-02-2022
Ward:GM Unit:2
Age/Gender : 16 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 15/07/2022 10:05 AM
Diagnosis
SICKLE CELL ANAEMIA IN VASO OCCLUSIVE CRISIS
Case History and Clinical Findings
PRESENTING Complaints:
C/O knee pain since 3 days.
HOPI:
14 year female presented with complaints of joint pains since 3 days; initially at the shoulder joint followed by the knee joint; no involvement of other joints. History of occasional morning stiffness, relieved after sometime. No history of headache,shortness of breath, chest pain, burning micturition. Now admitted for further management and treatment.
PAST ILLNESS :
At the age of 3, she had complaints of fever, SOB and fatigue, patient sought for consultation and diagnosed to be having sickle cell anemia and having low Hb. She underwent 2 units of PRBC transfusion. she underwent multiple PRBC transfusions every 6 months. She had complaints of fever, cough associated with severe respiratory distress and underwent 2 units of PRBC transfusion at the age of 5 years. In DEC 2014, she had diagnosed with Bronchopneumonia. Chest x ray revealed Right upper lobe consolidative changes. She underwent 2 units of PRBC transfusion. She was started on Penicillin prophylaxis since 7/7/15. At 9 years of age she had complaints of myalgia and arthalgia and underwent 2 units of PRBC transfusion. She was started on hydroxyurea and ecosprin by the sickle cell society.
GENERAL EXAMINATION:
Patient was conscius and coherent. Afebrile.
Moderately built and nourshied.
PR: 86bpm; BP: 110/70mmHg; SpO2: 98%@RA; RR: 21cpm.
CVS; S1, S2+; R/S: BAE,Clear; P/A: Soft, Non tender, BS+; CNS:
HMF+; NFND. GCS; 15/15.
Power in B/L upper and lower limbs was 5/5. Tone was normal.
Reflexes pressent with flexor plantars.
COURSE IN THE HOSPITAL:
14 year female presented with above mentioned complaints. Necessary investigations were done. Her Hb was 8gm/dl. She had frequent episodes of pain crisis through out the day, more at night. She was advised for adequate hydration. One unit of PRBC transfusion was done on 17/07/2022, which was uneventful. During the hospital stay she was treated with Analgesics, antibiotics and other supportive medications. Her HB at the time of discharge was 11 gram/dl. She has been discharged in a hemodynamically stable condition.
Treatment Given(Enter only Generic Name)
1. NORMAL DIET.
2. PLENTY OF ORAL FLUIDS.
3. TAB. HYDROXYUREA 500MG 1 TAB TWICE DAILY AFTER FOOD AT 8 AM - 8 PM.
4. TAB. PENICILLIN G 40000 IU ONCE DAILY AFTER FOOD AT 8 AM.
5. TAB. FOLIC ACID 5 MG 1 TAB ONCE DAILY AFTER FOOD AT 2 PM.
5. TAB. CIPCAL 500 MG 1 TAB ONCE DAILY AFTER FOOD AT 2 PM.
6. TAB. BECO ZINC 1 TAB ONCE DAILY AFTER FOOD AT 2 PM.
7. CALCIQUICK GRANULES IN 1 GLASS OF MILK ONCE IN 15 DAYS.
Advice at Discharge
1. NORMAL DIET.
2. PLENTY OF ORAL FLUIDS.
3. TAB. HYDROXY UREA 500MG 1 TAB TWICE DAILY AFTER FOOD AT 8 AM - 8 PM.
4. TAB. PENICILLIN G 40000 IU ONCE DAILY AFTER FOOD AT 8 AM.
5. TAB. FOLIC ACID 5 MG 1 TAB ONCE DAILY AFTER FOOD AT 2 PM.
5. TAB. CIPCAL 500 MG 1 TAB ONCE DAILY AFTER FOOD AT 2 PM.
6. TAB. BECO ZINC 1 TAB ONCE DAILY AFTER FOOD AT 2 PM.
7. CALCIQUICK GRANULES IN 1 GLASS OF MILK ONCE IN 15 DAYS.
Follow Up
REVIEW SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date
Date: 21/07/2022
Ward: FEMALE MEDICAL WARD Unit: GENERAL MEDICINE V
Age/Gender : 15 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 15/03/2023 05:05 PM
Name of Treating Faculty
Diagnosis
K/C/O SICKLE CELL ANEMIA SINCE 11YEARS ? WITH VASO OCCULSIVE B/L LOWER LIMBS AND NO E/O DVT
Case History and Clinical Findings
COMPLAINTS:
PATIENT CAME WITH COMPLAINTS OF PAIN IN BOTH KNEES SINCE AFTERNOON PAIN IN BOTH LOIN SINCE AFTERNOON
HISTORY OF PRESENT ILLNESS:
PATIENT WAS APPARENTLY ASYMPTOMATIC 3DAYS AGO THEN SHE DEVELOPED PAIN AT LEFT ANKLE AND TOOK ULTRACET TABLET TO SUBSIDE THE PAIN
FOM AFTERNOON SHE DEVELOPED PAIN IN BOTH KNNES AND AFTER AN HOUR SHE DEVELOPED PAIN IN BOTH LOIN WHICH IS SUDDEN IN ONSET,DURATION SINCE AFTERNOON,NO AGGREVATING AND RELIVEING FACTORS
H/O WEAKNESS AND FATIGUE PRESENT ALL PERIPHERAL PULSES ARE PALPABLE
NO H/O SWELLINGS OF HANDS AND LEGS NO H/O DIZZINESS
NO C/O CHEST PAIN,SHORTNESS OF BREATH,HEADACHE,PALPITATIONS PAST HISTORY:
H/O SIMILAR COMPLAINTS IN PAST FOR 3TIMES
AT THE AGE OF 3 SHE HAD COMPLAINTS OF FEVER,SHORTNESS OF BREATH,FATIGUE,PATIENT WAS DIAGNOSED AS SICKLE CELL ANEMIA AND UNDERWENT 20PRBC TRANSFUSIONS IN 11YEARS
LAST BLOOD TRANSFUSION WAS IN JAN 2023 H/O JAUNDICE 2YRS AGO
H/O CHOLELITHIASIS 3MONTHS AGO NOT A K/C/O DM,HTN,CAD,CVA,EPILEPSY EXAMINATION:
PATIENT IS C/C/C AFEBRILE
PALLOR AND ICTERUS PRESENT
NO CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMA VITALS:
TEMP:98F PR:80BPM BP:110/70MMHG RR:16CPM SPO2:98%AT RA CVS:S1S2 HEARD NO MURMURS RS:BAE PRESENT NVBS HEARD
P/A:SOFT,NON TENDER CNS:NFND
COURSE IN THE HOSPITAL:
PATIENT PRESENTED WITH COMPLAINT OF PAIN IN BOTH LOWER LIMBS FOR WHICH PATIENT IS SYMPTOMATICALLY TREATED AND SYMPTOMS GOT RELIEVED GRADUALLY.PATIENT HAS 2 FEVER SPIKES ON DAY 3 OF ADMISSION F/B NO FURTHER EPISODS OF FEVER.ICTERUS PROGRESSED FROM DAY OF ADMISSION TO DAY 5 AFTER WHICH IT DECREASED.PATIENT DID NOT TAKE MEDICATION FOR THE FIRST 3DAYS DUE TO AVAILABILITY ISSUE
CASEHAS BEEN DISCUSSED WITH PEDIATRICS TEAM I/V/O PENICILLIN USAGE AND THEY ADVISED TO STOP PENICILLIN AS PRIOR VACCINATION WAS GIVEN
USG OF LEFT LEG WAS DONE ON 3RD DAY OF ADMISSION I/V/O SWELLING IN THE MEDIAL ASPECT OF UPPER LEG AND IMPRESSION IS FOCAL THROMBOPHLEBITIS OF SHORT SEGMENT OF SUPERFICIAL VEIN OF UPPER LEG ON MEDIAL ASPECT
Investigation
BLOOD AND URINE CULTURE:NO GROWTH OF BACTERIA NO PUS CELLS SEEN
2D ECHO:NO RWMA NOAS/MS GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION NO PAH/PE
ARTERIAL AND VENOUS DOPPLER OF B/L LOWWER LIMBS:CFA,DFA,SFA,POPLITEAL,ATA,PTA,DPA AND CORRESPONDING VEINS ARE EXAMINED UNDER GRAG SCALE AND COLOUR DOPPLER
EXAMINED ARTERIES SHOWS NORMAL TRIPHASIC WAVEFORM WITH PSV AROUND 40 TO 110CM/S
NO E/O ANY HYPERECHOIC THROMBUS NOTED IN EXAMINED DEEP VEINS IMPRESSION-NO DVT
ARTERIES SHOW NORMAL TRIPHASIC WAVE FORM
USG ABDOMEN AND PELVIS IS DONE I/V/O SPLLEN SIZE AND ECHOTEXTURE FINDINGS:SIZE-8.3CM
SLIGHTLY HYPERECHOIC LIKELY CALCIFICATION OR CHRONIC INFRACTS
Treatment Given(Enter only Generic Name)
IV FLUID IONS@75ML/HR TRAMADOL 1AMP IN 100ML INJ.ZOFER 4MG IV/SOS TAB.PENICILLIN 800MG PO/OD TAB.HYDROXY UREA 1000MG PO/OD
TAB.ECOSPRIN 75MG PO/OD TAB.NODOSIS 500MG PO/TID TAB.SHELCAL 500MG PO/OD TAB.NAPROXEN 250MG PO/BD TAB.PARACETAMOL 650MG PO/SOS TAB.PAN40MG PO/OD/BBF
Advice at Discharge TAB.PENICILLIN 800MG PO/OD TAB.HYDROXY UREA 1000MG PO/OD TAB.ECOSPRIN 75MG PO/OD TAB.NODOSIS 500MG PO/TID TAB.SHELCAL 500MG PO/OD
TAB.PAN40MG PO/OD/BBF FOR 5DAYS TAB.ULTRACET 1/2 TAB PO/SOS
Follow Up
REVIEW AFTER 15DAYS OR SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date:15/03/23 Ward:AMC
Unit:GENERAL MEDICINE 3
Age/Gender : 15 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 25/07/2023 04:31 PM
Diagnosis
K/C/O SICKLE CELL ANEMIA SINCE 11 YEARS WITH VASO OCCLUSIVE CRISIS ( LEFT UPPER LIMB AND RIGHT LOWER LIMB) PYREXIA UNDER EVALUATION .
Case History and Clinical Findings
PATIENT CAME WITH C/O FEVER SINCE 3 DAYS WITH SWELLING OF RIGHT UPPER LIMB AND RIGHT LOWER LIMB SINCE SINCE 3 DAYS WITH PAIN .
FEVER OF GIGH GRADE NOT ASSOCIATED WITH CHILLS AND RIGORS NOT A/W COUGH,COLD,SORE THROAT,CHEST PAIN,PALPITATIONS ,SWEATING,ABDOMINAL PAIN
,VOMITING,NAUSEA,DIARRHOEA ,DECREASED URINE OUTPUT.
PAIN OF RIGHT LOWER LIMB SINCE 3 DAYS WITH PITTING EDEMA THEN PROGRESSIVELY PAIN OF LEFT UPPER LIMB ASSOCIATED WITH SWELLING AND LOCAL RISE OF TEMPERATURE
NOT ASSOCIATED WITH TINGLING SENSATION OF LIMBS,NUMBNESS,LOSS OF SENSATION. NO H/O HEMATURIA,MELENA,BLEEDING GUMS,PETECHIAE,DYSMENORRHOEA,MENORRHAGIA.
HISTORY OF SIMILAR COMPLAINTA IN THE PAST -4 EPISODES
K/C/O SICKLE CELL ANEMIA SINCE 11 YEARS ? WITH VASOOCCLUSSIVEW CRISES ( B/L LOWER LIMBS)
N/K/C/O HTN,DM,CVA,CAD,TB,EPILEPSY,THYROID,ASTHMA.
H/O BLOOD TRANFUSION PRESENT : MORE THAN 20 TRANSFUSION IN THE PAST 11 YEARS
.
PATIENT IS CONCIOUS,COHERENT,COOPERATIVE TEMPERATURE:98.8 F
PALLOR -PRESENT
NO ICTERUS,CYANOSIS,CLUBBING,GENERALISED LYMPHADENOPATHY PR;73 BPM
BP: 110/60 MMHG
CVS:S1S2 HEARD,NO MURMURS RS:BAE PRESENT ,NVBS
RR: 18CPM SPO2:99%
LOCAL EXAMINATION :ON INSPECTION EDEMA OF RIGHT LOWER LIMB PRESENT UPTO DISTAL HALF OF RIGHT LEG
EDEMA OF LEFT UPPER LIMB WHICH WAS PRESENT UPTO ELBOW.
ON PALPATION : PITTING TYPE OF EDEMA PRESENT UPTO 15 CM BELOW THE RIGHT KNEE JOINT OF RIGHT LOWER LIMB AND PITTING TYPE OF EDEMA PRESENT UPTO LEFT ELBOW JOINT.
LOCAL RISE OF TEMPERATURE IS PRESENT. TENDERNESS PRESENT
HOFFMAN SIGN,MOSSES SIGN NEGATIVE.
GENERAL SURGERY REFERRAL DONE ON 26/7/23 I/V/O ISHAEMIC CHANGES AND DVT OF LEFT UPPER LIMB AND RIGHT LOWER LIMB
ADVICE :RIGHT LOWER LIMB AND LEFT UPPER LIMB ELEVATION TAB CHYMEROL FORTE PO/TID
TAB PCM 650 MG PO/TID REVIEW WITH REPORTS
COLOUR DOPLLER ARTERIAL AND VENOUS OF RIGHT LOWER LIMB AND LEFT UPPER LIMB ORTHO REFERRAL DONE ON 27/7/23I/V/O ANY ISCHEMIC CHANGES INVOLVED IN BONE ADVICE : X RAY RIGHT FULL LENGHT LEG AP AND LATERAL VIEW
COLOUR DOPPLER LEFT UPPER LIMB
OPHTHALMOLOGY REFERRAL DONE I/V/O RETINAL CHANGES
IMPRESSION :ON BOTH EYES FUNDUS EXAMINATION ,NO RETINAL CHANGES NOTED .
Investigation
25/7/23
HB-6.7 GM/DL TC;19,500 CELLS/CUMM
N/L/E/M/B-60/28/3/9/0 MCH-33.2
PLT-3.40 LAKHS/CUMM LFT:
T.B-1.86
DB.O.70 SGOT-20 SGPT-13 ALP-206 TP-6.3
A/G RATIO-1.13 PT-18 SEC
INR 1.3
RETIC COUNT- O.5% SERUM IRON :90 ESR:90 MM/1 ST HOUR RFT
SE CREATININE: O.5 MG/DL NA/K/CL/CA-134/4.1/99/1.03 27/7/23
SE CREATININE -0.4 MG/DL NA/K/CL/CA-137/4.6/98/1.14 LFT:
T.B-1.44 DB.O.40 SGOT-21 SGPT-19 ALP-209 TP-6.1 A/G:1.28
BLOOD UREA:13
2DECHO :
MILD TR,TRIVIAL AR,NO MR NO RWMA.NO AS/MS
GOOD LV SYSTOLIC FUNCTION
NO DIASTOLIC DYSFUNCTION NO PAH/PE USG
IMPRESSION:
MILD HEPATOMEGALY
CHOLILITHIASIS WITH GB WALL EDEMA LEFT SIMPLE OVARIAN CYST
URINE FOR C/S:
NO PUS CELLS SEEN ,NO GROWTH.
Treatment Given(Enter only Generic Name)
IV FLUIDS 2. NS @ 75 ML/HOUR INJ NEOMOL 1 G IV/SOS
INJ TRAMADOL IV/TID T.HYDROXYUREA 500 MG PO/BD TAB SHELCAL CT PO/OD T.OROFER XT PO/OD
TAB CHYMEROL FORTE PO/TID TAB PCM 650 MG PO/TID
Advice at Discharge T.HYDROXYUREA 500 MG PO/BD TAB SHELCAL CT PO/OD T.OROFER XT PO/OD
TAB CHYMEROL FORTE PO/TID X 5 DAYS
Follow Up
REVIEW TO GENERAL MEDIINE OPD SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date:28/7/23 Ward:GM WARD
Unit:2
17-11-2024
PPM 2-
PPM 2 - She had 3 fever spikes today since admission sir.
The last one was at 5 pm today. 101F.
PPM 1 - Please share her fever chart ASAP.
On 19-11-2024
Her current treaatment chart?
PPM 2 - We are giving IV fluids.
Tab.Tramadol
Tab.Hydroxyurea
Tab.Folic acid
Tab.PCM
O2 supplementation.
We have added Tab.Augmentim today in view of suspicion of LRTI sir.
PPM 1 - 👍
PPM 3 - Is it LRTI or acute chest syndrome.? Any documented fever?
@PPM2?
Sorry to miss that...she was admitted with chest syndrome once sir.
PPM 2 - We thought of acute chest syndrome initially sir but she had 3 fever spikes so far.
no cough or any other symptoms. Will share the fever chart sir.
PPM 1 - Does fever negate acute chest syndrome?
What's the respiratory rate since admission?
PPM 2 -No sir fever can be there in acute chest syndrome too.
Her RR since admission is 16 sir
PPM 1 - 👍
PPM 3 -
Ai :
Let me analyze this chest X-ray with the provided clinical context.
Radiological Findings:
1. There is a prominent bilateral perihilar infiltrative pattern
2. Patchy areas of consolidation in the lower lung zones bilaterally
3. Normal cardiac silhouette
4. No pleural effusion visible
5. No pneumothorax
6. Rib cage and bony structures appear normal
Clinical Correlation:
Given the patient's history of:
- Sickle cell disease
- Fever (101°F)
- Elevated WBC count (32,000)
- Elevated bilirubin levels
- Respiratory symptoms (cough)
Radiological Impression:
The findings are highly suggestive of Acute Chest Syndrome (ACS), a serious complication of sickle cell disease. The bilateral infiltrates and consolidation pattern is classic for ACS, which can be triggered by infection, fat embolism, or sickling within the pulmonary vasculature.
Recommendations:
1. Immediate hospitalization if not already admitted
2. Blood cultures
3. Broad-spectrum antibiotics
4. Consider incentive spirometry
5. Adequate hydration and pain management
6. Close monitoring of oxygen saturation
7. Consider exchange transfusion based on clinical severity
This appears to be an urgent clinical situation requiring prompt management given the combination of radiological findings and concerning lab
PPM 3 - Clinical Decision supporting tool.
PPM 4 - Which tool sir?
PPP 3 - Claude.
PPM 4 - 👍
18-11-2024
PPM 2 -
Update:
C/o
breathlessness ,Chest pain,Epigastric pain
since yesterday night
Continuous fever spikes present
Auscultation:
crepts present in B/L lung fields,predominantly basal
Room air spo2-82-84
93% on 6lit O2
@PPM5 share the fever chart and todays investigations here asap
PPM 1 - I guess I need to prepare the fever chart in the afternoon.
Assuming she was in ICU or AMC let's at least hope that data will have been recorded(unlike what happens in ward where even temperatures are not recorded)
On how much Fio2? (ABG)
PPM 2 - Room air sir.
Will update the fever chart now sir.
PPM 1 - For how long was she on room air before that? since morning?
PPM 2 - Her room air sats were around 94 yesterday morning sir.
As ICU is closed we needed beds in AMC. So we shifted her to ward, but she was having continuous
fever spikes too. So shifted her to AMC in the evening for better monitoring. Then we found Spo2 is less.
PPM 1 - 👍
So 24 hrs on room air before that ABG?
PPM 2 - Yes sir.
PPM 1 - Is all the 4 hrly temperature data in the nursing chart? Shall I come over right now to prepare the graph?
PPM 3 -ABG shows slightly hypoxia and Co2 washout....?
What is her RR...? @PPM2
PPM 1 - Particularly the charted trends.
PPM 2 - 22-24 sir.
PPM 1 - Thanks for sharing the graph. She is worsening.
Need to see her respiratory rate trends since admission.
PPM 3 - @PPM2 Can you summarize her current clinical trend?
PPM 3 -
AI:
1. Clinical Progression:
- Persistent fever spikes (38-39°C) over 3-4 days
- Respiratory rate progressed from 16 to 20-24/min
- Temperature chart shows no sustained response to antipyretics
2. Laboratory Trends:
Hematology:
- Hemoglobin dropping: 8.1 → 5.78 → 5.7 g/dL (severe anemia)
- WBC rising: 19,700 → 22,000 → 32,000 (worsening inflammation)
- Platelets stable but low: 2.23 → 2.44 → 2.7
Liver Function:
- Total bilirubin: 6.6 → 18.2 → 15.23 mg/dL
- Direct bilirubin: 1.9 → 13.14 → 8.83 mg/dL
- AST/ALT: 66/26 (hepatocellular pattern)
- Low albumin: 3.5 g/dL
3. Integrated Assessment:
This represents a severe case with:
- Acute Chest Syndrome
- Hepatic sequestration/sickle hepatopathy
- Severe hemolysis
- Systemic inflammatory response
4. Updated Management Algorithm:
Immediate Actions:
a) ICU Transfer if not already there
b) Respiratory Support:
- O2 therapy targeting SpO2 >95%
- Prepare for possible NIV/intubation
- Continue incentive spirometry if able
c) Urgent Exchange Transfusion indicated due to:
- Severe ACS
- Dropping hemoglobin
- Hepatic involvement
- Target Hb 10g/dL
- Reduce HbS to <30%
d) Infection Management:
- Broad-spectrum antibiotics
- Consider adding atypical coverage
- Blood cultures if not done
e) Liver Protection:
- IV hydration with careful fluid balance
- Monitor coagulation profile
- Consider ursodeoxycholic acid
- Regular liver function monitoring
f) Supportive Care:
- Pain management
- DVT prophylaxis
- Close monitoring of fluid balance
- Nutrition support
5. Monitoring Parameters:
- Q4h vitals with continuous SpO2
- Daily CBC, LFTs
- 12-hourly ABG
- Input/output charting
- Serial chest X-rays
6. Prognosis:
- High-risk situation
- Multi-organ involvement
- Requires aggressive intervention
- Need for close monitoring for further deterioration
The combination of worsening ACS with hepatic involvement makes this a particularly severe case requiring immediate aggressive intervention. The priority is exchange transfusion while supporting respiratory function and treating underlying infection.
PPM 3 -
How ever for the same patient we discussed with peads department for exchange transfusion way back in her first admission with Acute chest syndrome but they told it was not done till then even in there department.
PPM 1 - The question is would it have been efficacious?
PPM 5 - How steroids are going to help her sir??
Or it's due to pulmonary infarction.
PPM 1 - 👍
Infection causes inflammation
Infection may or may not be diagnosed or get the right chemical (pharmacological)
And the diagnosis could also be pulmonary inflammation due to vascular occlusion bordering on pulmonary infarction
Steroids are just non specific anti-inflammatory agents used in sepsis:
19-11-2024
PPM 1 - Share her fever chart with the soap notes for each day.
PPM 1 - 👍
PPM 2 - Ok sir.
Sir shall we plan a PRBC transfusion today or it's not necessary?
PPM 1 - Let's watch how long she takes to recover without it as giving PRBC could trigger hemolysis.
PPM 2 - Ok sir.
20-11-2024
PPM 1 - Today's update? @PPM2
C/O breathlessness fever and cough decreased.
Sats on room air - 84%
96%on 3 lit O2
PPM 1 - 👍
PPM 2 - Asculation: Crepts is Right IAA,MA,ISA
Left IAA and ISA
PPM 1 - The sickle Cell crisis storm appears to have abated in this 15F.
21-11-2024
PPM 2 - Subjectively feels better than yesterday.
22-11-2024
PPM 2 -
C/O cough decreased
No C/O Breathlessness
Apetite improved.
No thrombophlebitis.
PR - 102 bpm
BP - 120/80 mmhg
RR - 20 cpm
Spo2 - 92% @ RA
Auscultation: crepts + in right IAA, ISA, MA and left IAA.
Plan to repeat hemogram and LFT tomorrow.
23-11-2024
PPM 2 -
Cough and breathlessness subsided.
Had an episode of sudden onset pain in the right side of Chest and upper back, resolved with medication at 11pm yesterday.
PR - 96 bpm
BP - 110/70 mmhg
RR - 26 cpm
Spo2 - 90% on RA
Plan:
Shall we restart her on steroids again?
And continue Augmentin further?
@PPM 1 sir.
PPM 1 - Yes 👍
The WBC counts trends are steadily falling and the HB is increasing.
PPM 2 - Yes sir
Shall I start her on Inj.Hydrocort again or switch to oral steroids sir?
PPM 1 - Oral should be fine.
Prednisolone 30mg once daily.
PPM 2 - Okay Sir.
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