Name : K.Keshitha

Roll no : 64

9th semester.

This is 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 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 comment box is welcome .

I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis .

13 year old male patient complaining of yellowish discolouration of eyes and yellow urine.

Following is a brief about the case,

(History as per date of admission).

CHIEF COMPLAINTS:

A 13 year old male child, studying in grade 7 at a school in Miryalguda was brought to the Medicine OPD (on 6/01/2022) with complaints of:

• Yellowish discolouration of eyes since 9 days

• Dark coloured urine since 9 days.

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic as a newborn - healthy term baby, cried immediately after vaginal delivery.

He had physiological jaundice that resolved spontaneously.

He is immunized as per schedule.

At 8 months of age: he developed altered bowel habits - 1 week of passage of loose stools followed by 1 week of passing normal stools.

Later he continued to pass loose stools for 2-3 months and became cachetic.

He was taken to the hospital where he was given IV antibiotics and 2 FFP transfusions.

He recovered in about 3 months time and according to hospital discharge summary, he was suspected to be suffering from :

• Celiac disease

• Chronic diarrhea

• Chronic Malabsorption

On further inquiry, the parents said that he used to have recurrent cold, coughs and fever. He also has used inhalers - during winters - for 1 year.

He wasn't admitted to a hospital at any point.

There is no history of Pneumonia.

At 9 years of age : parents noticed a swelling in the neck and took him to an ENT doctor. From there he was referred to an endocrinologist where he was diagnosed with Hypothyroidism.

Medication used - Thyronorm - initially 150 mcg, later increased to 180mcg, everyday.

There is history of chronic itching over palms and foot since 9 years of age - Dermatologist prescribed medications for dry skin.

At 12 years of age : he had Chicken pox that resolved in about 10 days time.

Now , at 13 years of age

It started with 2 episodes of bilious nomn projectile vomiting before food intake

Following that yellow coloured urine and yellowish discolouration of eyes was seen

This complaints occured 9 days before hospital admission

No fever

No pain abdomen

No loose stools/ clay colored stools

No history of small joint pains

He was treated by a local pediatrician, but because of constant rise in bilirubin levels he was referred here for further treatment.

HISTORY OF PAST ILLNESS:

• There is no history of similar complaints in the past.

• He is on regular medication for Hypothyroidism for past 5 years.

• He is not a known case of DM, HTN, ASTHMA,TB, EPILEPSY.

• No history of surgeries in the past.

FAMILY HISTORY:

He is a 4th order child ,born out of grade 3 consanguinous marriage.

He had one elder sister - who expired at 5 years of age.

He has 2 elders brothers.

His sister was the first child.

She was asymoptomatic till 2 years of age ,then she developed shortness of breath and was rushed to hospital,where here condition detiorated and had to be admitted.

She was diagnosed to have splenomegaly and her blood counts were decreasing.

She was given multiple blood transfusions, every 25 days,for one year- but remained anemic.

She also underwent bone marrow biopsy twice .

According to parents she was given steriods for one year before her death.

She never had jaundice or recurrent infections.

Eldest brother is 19 year old and second brother is 16.

Second brother had history of fever and white coloured loose stools at the age of 5 years , for which he was taken to the Nalgonda hospital.

He recovered on medication.

He was also diagnosed with anemia from which he recovered with some medications.

No history of Jaundice in this brother.

GENERAL EXAMINATION:

Consent of the patient taken.

The patient is conscious,coherent and cooperative; well oriented to time,place and person.

He is sitting comfortably on the bed.

He is lean build and moderately nourished.

• Height - 156cm

• Weight - 32kgs

• Pallor- present

• Icterus - present

• Clubbing - absent

• Cyanosis - absent

• Lymphadenopathy - absent

• Edema - absent

Vitals : Temperature - afebrile

Pulse - 100bpm

BP - 120/70 mmhg

RR - 18cpm

He has scars from his recent Chickenpox infection on limbs and trunk.

SYSTEMIC EXAMINATION:

ABDOMEN EXAMINATION

INSPECTION:

Shape – scaphoid

Flanks – free

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving with respiration.

No dilated veins, hernial orifices , sinuses

No visible pulsations

PALPATION:

Soft, non tender

Spleen:

Palpable in left hypochondrium enlarging towards the Right Iliac Fossa , it moves with respiration

It is firm in consistency with a smooth surface and a rounded edge

Liver and kidney are not palpable.

PERCUSSION:

There is no fluid thrill , shifting dullness.

Enlarged spleen is dull on percussion.

AUSCULTATION:

Bowel sounds are heard.

CARDIOVASCULAR SYSTEM

INSPECTION:

Chest wall - bilaterally symmetrical

No dilated veins, scars, sinuses

Apical impulse is appreciated

PALPATION:

Apical impulse is felt on the left 4th intercoastal space 2cm away from the midline.

No parasternal heave, thrills felt.

PERCUSSION:

Right and left heart borders percussed.

AUSCULTATION:

S1 and S2 heard , no added thrills and murmurs heard.

RESPIRATORY SYSTEM

INSPECTION:

Chest is bilaterally symmetrical

Trachea – midline in position.

Chest is moving normally with respiration.

No dilated veins, scars, sinuses.

PALPATION:

Trachea – midline in position.

Apical impulse is felt on the left 5th intercoastal space.

Chest is moving equally on respiration on both sides

Tactile Vocal fremitus - appreciated

PERCUSSION:

The following areas were percussed on either sides-

Supraclavicular

Infraclavicular

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapular

Upper/mid/lower interscapular were all RESONANT.

AUSCULTATION:

Normal vesicular breath sounds heard

No adventitious sounds heard.

Liver and Kidney are not palpable.

CENTRAL NERVOUS SYSTEM EXAMINATION.

HIGHER MENTAL FUNCTIONS:

Patient is Conscious, well oriented to time, place and person.

All cranial nerves - intact

Motor system

Right. Left

BULK

Upper limbs. N. N

Lower limbs N. N

TONE

Upper limbs. N. N

Lower limbs. N. N

POWER

Upper limbs. 5/5. 5/5

Lower limbs 5/5. 5/5

Superficial reflexes and deep reflexes are present , normal

Gait is normal

No involuntary movements

Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are

well appreciated .

INVESTIGATIONS:

Investigations ordered are : ECG, Hemogram, Bleeding and clotting time, prothrombin time, APTT, Urine analysis, Serology, liver function tests,renal function tests , blood grouping ,cross matching,coomb's test , Stool for occult blood amd parasite ,USG - Abdomen.

Hemogram:

• There is significant drop in hemoglobin- from 8.9 to recent Hb -5 units.

• Leucopenia.