14/F chronic Pain Abdomen

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I've 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 a diagnosis and treatment plan.

14 year old

Female

Student 

History sequence of events since 1yr till current admission :

Pain abdomen since 1 year ,in the epigastric region, on&off ,burning type,non radiating,associated with food intake ,associated with vomitings occasionally, relieved on medication.

H/O regurgitation of food present .

Usg abdomen done in Aug ,2023 showed ruptured hemorrhagic ovarian cyst with mild fluid collection in POD,not active treatment was given 

Review scan in jan 2024 showed no sonological abnormality 

H/o 3-4 episodes of loose stools in April

H/O fever 1 month back ,subsided with treatment

Dengue IgM -slightly positive

Widal - 0 &H 1:160

Hb-10.5

Plt count - 2.23L

Wbc -11K

But now having fever again since 1 wk ,high grade with chills 

Pedal edema and facial puffiness since 1wk 

Pain abdomen since 1 wk

Past History:

Regular outside food consumption 

Family History :

H/O 2 spontaneous deaths of children with in 1yr born prior to her .

4 members in the family

Siblings - One elder brother ( Intermediate 1st yr ):healthy 

Birth History :

Had ?CSF tap done in early childhood in view of fever and staring ,uprolling of eye balls with stiffness of neck and limbs 

No documentation available (pt attenders were told the test was normal )

Menstrual history :

O/E -

Pallor +

No Pedal edema and facial puffiness 

P/A - soft ,Tenderness present in epigastrium ,no organomegaly

Hemogram - mild leucocytosis with mild mc/hc anemia and normal plt count

CUE - No albumin loss

Dengue and Mp -negitive

Widal -no significant rise in titres

Esr -15 ,normal

CRP -2.4 ,positive 

LFT ,RFT - normal

Thyroid profile -normal 

Usg abd -No sonogical abnormality detected

Ecg -

P wave in lead 2 -2 small boxes

No RAD & RVH changes 

Chest xray -

?Enlarged right atria and right  descending pulmonary and central pulmonary artery 

2D echo -

TR + , mild PAH

Problem statement and Conclusion:

1.No relation between pain abdomen and fever ?

-As it is present since long back 

2.Cause for fever again ?

-Is it just a seasonal flu with fever 

3.No fever spikes since admission 

4.No pedal edema and facial puffiness noted since admission

5.Blood investigations and imaging showed no particular organ involvement corresponding with fever or abdominal pain

7.Cause for PAH ?

-No severe Anemia, polycythemia or Hyperthyroidism 

-No H/o congenital heart disease (valvular diseases/septal defects)

-No causes found which leading to Left heart failure causing RH involvement & PAH

8.Any coagulation defects ,PE causing mesenteric ischemia causing pain abdomen ?

-Less likely

9.Any autoimmune association possible ?

-less likely

10.GERD causing PAH in this case ?

11.Is mild form of PAH normal ?

Diagnosis in consideration :

Viral pyrexia

GERD ,Gastritis

Typhlitis

IBS

Plan :

Review echo for Right heart on Echo ?

UGIE ?

Discussion around the patient :

Chandana Mam SR - 52rvsp in 14yr female 😑definitely abnormal..PAH present..

And more detailed history is needed @⁨Prachethan⁩

Me -Okay mam

https://prachethanreddy.blogspot.com/2024/07/14f-chronic-pain-abdomen.html?m=1

Chandana Mam SR - Good

Could that pedal edema she had previously was due to DVT in which the thrombus has migrated to pulmonary artery causing PAH?

Could it be chronic mesentric thrombosis in that case?

Will d dimer and lower limb venous doppler help?

In case the clot has migrated lower limb doppler may be normal

She went to outside hospital with tachycardia and desaturation. Was that an acute PE episode? But she had chills and not SOB?Document old record also in the blog…search for such presentations and spontaneous resolution.

Me -1.I feel DVT is less likely mam

No relevant significant history mam

There is H/O edema of both legs along with even facial puffiness

And there is no associated pain in legs

2.Mesenteric ischemia is a possibility but less likely mam

4.I feel Ddimer and Doppler will be normal mam

5.Acute high grade fever with severe chills (pt was not able to lie down )may cause some hypoxia transiently mam ?

Chandana Mam SR - Okay 

But If lung parenchyma and left heart are normal the next thing we need to investigate for PAH is CPTEH (chronic pulmonary thromboembolic hypertension)

What about her mother? Details of her Miscarriages

Me -No Miscarriages mam but first 2 child died with in the first 1 yr

Cause not known