13 yr F co-morbid with sickle cell anaemia with sickle 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
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
Comments
Post a Comment