GM case -6

GM case -6

March 7 , 23

A 23 year old girl came with a chief complaint of abdominal pain since 1 yr and left sided chest pain since 1 yr.


My self Anu Bandlagudem of 3rd BDS .This is an online E log book to discuss our patients de- identified health data shared after taking her guardian's signed informed consent.Here we discuss our individual patients problem through series'of inputs from available global online community of experts with aim to solve those patients clinical problems with collective current best evidence based inputs.
I have been given this case to slove in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history, findings, investigations, diagnosis and treatment plan.

Chief complaint:
Abdominal pain in upper quadrant ( Right hypochondrium) since 1 year and left sided chest pain since 1 year aggregated on exertion.

History of present illness:
Patient is apparently asymptomatic since 9 years .She developed dragging type of pain at left hypochondrium towards left sternal region since 9 yrs. She has swelling in left hypochondrium gradually progressive in nature. Pain lastes about 1 hr. On and off headache in frontal region. On and off fever 
Aggregating factor- in supine position
Releiving factor- in prone position

History of past illness:
At age of 13 yrs pain started went to local hospital and used medicine.
Frequency of pain - once in month 
At the age of 16 yrs age developed shortness of breath on exertionand fatigubility ,gizziness( monthly once) - pain and frequent onset of fever went to hospital then found out decreased Hb and k and used iron preparation tablets - used for about 1 month.
Frequent tingling of upper and lower limbs and pain aggregated upon prolonged sitting.
Decreased vision.
No Hypertension
No diabetes

Family history: 
Not a known case of hypertension, diabetes mellitus, tuberculosis, asthma.

Personal history:
Single child works as store manager
Diet- mixed
Appatite - loss of apatite
Sleep - normal
Bowel- regular
Micturition - regular

General examination:
Pallor- seen
Icterus- no
Cyanosis - no
Clubbing - no
Lymphadenopathy- no
Edema - no

Vitals:
Temperature- 98.6F
PR-86
RR-16 cycles/min
BP-110/70 mmHg
SP-98%
GRBS-120mg%

Systemic examination:
Inspection:
Oral cavity - Healthy
Caries- Absent
Gums- Healthy 
Umbilicus - inverted,central
Abdomen - scaphoid
No dilated veins
No scratches , black scars around umbilicus 
No sinuses 
No visible pulsations.
Palpation:
Superficial palpation -No local rise in temperature
Deep palpation - No tenderness on palpation in epigastric region.
Spleen palpable - left hypochondrium below coastal region.
Liver palpable.
No palpable pulsations.
Percussion:
No fluid thrill/ shifting dullness
Auscultation :
Bowel sounds - 5 / min

Investigations:
Hb- 6.1
Rbc- 3.5 million,microcytic hypochromic
Wbc-1900 reduced count in smear
Platelets - 48000 reduced count in smear 

Provisional diagnosis:
Hepatomelagy
Splenomegaly

Definitive diagnosis:
Pancytopenia

Questions:
Blood transfusion can solve this issue?
Age is related to hepatosplenomegaly??( Aged persons..more chances like that??)

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