Final short case

 


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 


February 1 2022 ( date of admission)

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 she developed epigastric pain which is severe and radiating ,gradually progressive, 2 episodes of vomiting since 2 days with food as content .

PAST HISTORY - 

K/C/O sickle cell anaemia since 2012  

History of bronchopneumonia

History of sickle cell crisis 2016

Hitory 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

SLEEP - Adequate


FAMILY HISTORY 

Similar complaints in the family is seen 

IMMUNIZATION HISTORY: 

Patient is vaccinated according to National immunization schedule,

Pneumococcal, typhoid, hepatitis vaccine taken on 23/1/22


GENERAL EXAMINATION:

PATIENT IS CONCIOUS , COHERENT COOPERATIVE

ICTERUS 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 cpm

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

PER ABDOMEN - DIFFUSE TENDERNESS PRESENT, NO ORGANOMEGALY

INVESTIGATIONS:










DIAGNOSIS: 

sickle cell anemia

Acute pancreatitis secondary to cholelithiasis ?

Secondary to pneumonia with right lower lobe consolidation..

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


Comments

  1. Goji Berries... yes... I tried those too.For my health conditions, Those sweet, red berries seemed to help, but only during the time when I consumed them. I don't want to take a drug for the rest of my life, so why would I want to take a natural supplement everyday for the rest of my life (although Goji berries are very tasty and are highly nourishing). To me this was not a cure either (and I'm LOOKING for the CURE).
    Up to that point, I hadn't found a cure. I felt like a young jumbled mess. I continued to have extreme pain, but continued on my path to healing. I started to focus on myself and not everyone else. When I was a young adult, I took on too much responsibility out of a sense of obligation. This was no longer healthy for me, so I resigned from all my projects and groups. Those days to come were the best [and worst] days. I took a lot of time off work, yet began to feel so extremely exhausted. Many health professionals "diagnosed" me with adrenal fatigue & Hiv,Prostate Cancer so my situation was annoying then I keep searching for permanent cure online that's when I came to know of Dr Itua herbal center hands whom god has blessed with ancestral herbs and a gift to heal people with diseaseSo I made a purchase of his herbal medicines and I have been watching my health for 6 years now and I actually confirmed that his herbal medicines are a permanent cure and I'm so happy that I came to know of his herbal healings.You can contact Dr Itua herbal center Email: drituaherbalcenter@gmail.com www.drituaherbalcenter.com if you went through exactly what I go through in terms of health conditions because to be honest there is more to learn about natural herbs than medical drugs.

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