SICKLE CELL PRESENTATION.pptx case study

Case study

1. SICKLE CELL PRESENTATION PRESENTERS:CHISHIMBA MWAPE AND HARRIET PHIRI MODERATOR :DR TUMBA

2. DEMOGRAPHICS NAME: GIFT MWEWA AGE: 11 SEX: M TRIBE: BEMBA RESIDENCE: LUANGWA RELIGION: CHRISTIANITY(UCZ) REFERAL: SOS CLINIC DOH: 24/06/24 DOA: 18/06/24

3. PRESENTING COMPLAINTS BODY HOTNESS X 7/7 BACK PAIN X 7/7 CHILS X 7/7 HEADACHE X 7/7

4. HISTORY OF PRESENTING COMPLAINTS THE PT IS A KNOWN SCD DIAGNISED IN FEBRUARY FROM KTH WHO PRESENTED WITH THE ABOVE SYMPTOMS.THE PT EXPERIENCED A HEADACHE,BACKPAIN AND CHILLS FOR A WEEK AND WAS TAKEN TO SOS CLINIC WHERE HE WAS TESTED FOR MALARIA AND WITH A POSITIVE RDT WAS INITIATED ON COATERM AND PARACETAMOL BUT THE SYMPTOMS DID NOT RESSOLVE.THE PT WAS THEN REFERED TO KTH.THE PT COMPLAINED OF BODY HOTNESS AND CHILLS WHICH WERE ASSOCIATED WITH GNERALIZED BODY PAIN AND BODY WEAKNESS,THIS WAS ACCOMPANIED BY A THROBBING HEADACHE FROM THE OCCIPITAL REGION OF THE HEAD WHICH WAS GRADUAL IN ONSET,IT WAS NON RADIATING AND WAS NOT ASSOCIATED WITH ANY CONVULSIONS,CONFUSION,BLURRED VISION OR LOSS OF CONSCIOUSNESS. THE PT ALSO COMPLAINED OF SEVERE BACK PAIN WHICH WOULD WORSEN UPON STANDING AND THE PT WOULD FEEL BETTER WHEN LYING DOWN.IT WAS ASSOCIATED WITH LEG PAIN BILATERALLY HOWEVER IT WAS NOT ASSOCIATED WITH ANY JOINT SWELLING OR RASH.THE PT HAD HISTORY OF YELLOWING OF EYES.THERE WAS NO FEVER,NO COUGH,NO NIGHT SWEATS AND NO SIGNIFICANT WEIGHT LOSS.

5. REVIEW OF SYSTEMS CVS-no cough -no palpitations -no dyspnea -no difficulties in breathing GIT-no diarrhea -no vomiting -no abd pain GUT-no polyuria -no hematuria -no dysuria -no hesitancy or incontinence RS-no sore throat -no SOB -no chest pain -no coughing of blood

6. PAST MEDICAL HISTORY HISTORY OF HOSPITAL ADMISSION IN FEBRUARY FOR A SIMILAR ILLNESS NO OPERATIONS NO SURGERY NO HISTRORY OF DIABETES,EPILEPSY,ASTHMA,TB,HYPERTENTION. RVD NR-VERBALLY

7. DRUG HISTORY HISTORY OF FOLIC ACID,HYDROXYURIA,COATERM AND PARACETAMOL NO KNOWN DRUG ALLERGY NO KNOW FOOD ALLERGY

8. BIRTH HISTORY PREGNANCY WAS 9 MONTHS DELIVERED VIA SVD AT LUANGWA CLINIC BW;3.1Kg THE MOTHER ATTENDED ANTENETAL VISITS AND TOOK HEMATINICS AND FANCIDAR DURING PREGNANCY

9. IMMUNIZATION IMMUNIZATION WAS UP TO DATE UNDER FIVE CLINIC CARD WAS CHECKED

10. NUTRITION HISTORY EXCLUSIVE B/FEEDING UP TO 6 MONTHS STOPPED B/FEEDING AT 1Y 4 MONTHS

11. DEVELOPMENTAL HISTORY SMILE -3MONTHS STAND-6 MONTHS WALK-1YEAR

12. FAMILY HISTORY NO HX OF DIABETES,ASTHMA,EPILEPSY,TB,SICKLE CELL

13. SOCIAL HISTORY PT STAYS WITH HIS PARENTS HAS ONE SIBLING(16YRS) FATHER WORKS AND MOTHER DOES NOT WORK DRINK CHLORINATED WATER FROM THE WALE SLEEPS UNDER A TREATED MOSQUITO NET NO HX OF SMOKING

14. SUMMARY I have presented GM M/11 a known scd patient who came in as a referral from sos clinic with complaints of body hotness,backpain,headache and chills for a week. The pt had generalized body pain and body weakness, There was bilateral leg pain, there was hx of yellowing of eyes, hx of hospital admission for a similar illness and drug hx of folic acid,hydroxyurea,coaterm and paracetamol however there was no history of any joint swelling,fever,cough,night sweats or any significant weight loss.

15. DIFFERENTIALS VOC IN A KNOWN SCD UNRESOLVED MALARIA ENTERIC FEVER

16. EXAMINATION GC; The pt was lying in supine position,alert,ill looking but was not in any obvious RD. There was a cannula In situ on the right hand. The pt was well nourished and was not dehydrated as there were no sunken eyes and the mucus membranes were moist. On close inspection, the pulse rate was 120bpm regularly regular with full volume, there was no collapsing pulse, no radial radial delay and capillary refill time was less than 2 seconds. There was pallor+++,jaundice + with no cyanosis and no lymphadenopathy

17. CVS-on inspection, there was a normal active precordium -on palpation, the apex beat was felt in the 5 th intercostal space mid clavicular line -on auscultation,s1 and s2 where heard,tachycardic with no added sound RS-on inspection, the chest was moving with respiration there were no scars, no deformities, no surgical marks, no traditional marks and the trachea was centrally located. on palpation, there was normal chest expansion on percussion, there was resonant to percussion -on auscultation, vesicular breath sounds were heard bilaterally with no added sound GIT-on inspection, there was abdominal distention on the left side -on palpation, the spleen was enlarged -on auscultation about 4-5 bowel sounds were heard MSS-no pedal edema bilaterally

18. URINALYSIS NO SIGNIFICANT FINDING

19. SUMMARY I EXAMINED GM M/11 .ON EXAMINATION,THE PT WAS ILL LOOKING,HAD A PULSE OF 120BPM REGULARLY REGULAR AND OF FULL VOLUME.THERE WAS PALLOR +++,JAUNDICE + AND SLEENOEGALLY ON ABDOMINAL FINDINGS.

20. IMPRESSION VOC IN A KNOWN SCD PT UNRESSOLVED MALARIA ENTERIC FEVER SLEENIC SEQUESTRATION

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