PROTEIN ENERGY MALNUTRITION
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I have 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 and treatment plan.
A 15 year old patient came to OPD with a chief complaint of fever since one month , swelling of lower limbs , cough.
HISTORY OF ILLNESS:
c/o fever - 1 month
c/o facial puffiness - 15 days
c/o B/L pedal edema - 20 days
c/o abdominal distension - 20 days
c/o cough - 5 days
c/o SOB , easy fatigability - 1 month
c/o night blindness
No history of previous blood transfusion
PERSONAL HISTORY :
Mixed diet
Bowel and bladder movements normal
Sleep adequate
VITALS :
Patient is febrile
PR : 124bpm
BP : 100/70 mmHg
CVS: S1 S2 + loud ejection systolic murmure in pulmonary arch
RS : BAE +
Soft on palpitation
Spleenomegaly +
INVESTIGATION :
CREATININE : 0.9 mg
Hemoglobin : 4 gm
TOTAL RBC COUNT : 3.1 mill./cm
TOTAL WBC COUNT : 3000cmm
Platelets count : 70000
DIAGNOSIS :
Protein Energy Malnutrition with severe anemia , night blindness. Later diagnosed with jaundice .
MEDICATION :
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