13 year old female with abdominal pain and vomiting

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 patient's 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 the comment box is welcome."

Chief complaints-abdominal pain and vomiting 

History of present illness 

Adominal pain since one day and 3 episodes of vomiting ,vomitings are watery ,non bilious , non projectile

Past history 

Patient is a known case of sickle cell anaemia .

Family history 

No significant family history 

Drug history 

Hydroxyurea  100mg/day

Pentid 600mg/day 

Soda mint

Folvide -5mg 

Calcium 500mg

Zevit -OD 500mg

Ecosprin-75mg

personal history 

She is student studying in class 7 

Diet -mixed 

Sleep -adequate 

Bowel and bladder -regular 

Appetite -adequate 

Addictions -none 

General examination 

Patient is conscious coherent and cooperative ,well oriented to time ,place and person 

Moderately built and moderately nourished 

Pallor present 

Icterus present 

Vitals 

• Temp-febrile 
• BP-110/g70mmhg
• HR-105
• RR-24cpm
• 
  
  
  
  
  CVS -s1,s2 heard 
  Apex beat -heaves heard 
  
  
  Resp-BAE-present 
  vesicular breath sounds -heard 
  
  
  CNS-no focal neurological deficits 
  
  
  GIT -tenderness over epigastric ,left hypochondriac radiating to left subscapular region
  No organomegaly

  

  
  

  
  

  
  

  

  
  

  Treatment given 

  tramadol 100ml ampule

  Inj Pantoprozol 

  NS DNS-75ml/l

  Inj Optineuron

  Diclo inj 

  
  

  Investigations 

  
  

  

  
  

  
  

  

  
  

  
  

  
  

  
  

  

  
  

  

  
  

  

  
  

  

  
  

  

  
  

  

  
  

  

  
  

  

  
  

  
  

   

  
  

  Provisional diagnosis 

  sickle cell anemia with jaundice 
  
  
  
  
  
  
  

  

  
  vascular occlusion crisis ? 
                     Peritoneal microinfarct ?