NEUTROPHILIA

1. BY
DR RABIA
PGR WEST MEDICAL WARD

2. BIODATA
NAME-------------IHTASHAM
AGE------------13
OCCUPATION--------STUDENT
MARRITAL STATUS ------UNMARRIED
RESIDENCE----------MUGHAL PURA LAHORE
DOA ----------29/11/13
MOA---------EMERGENCY

3. PRESENTING COMPLAINTS
 FEVER -------3 DAYS
 SORE THROAT ----------------3 DAYS
 PAINFUL DISCRETE SWELLINGS IN NECK WITH
DIFFICULTY IN MOVING NECK------------3 DAYS

4. HOPC
PATIENT WAS IN USUAL STATE OF HEALTH 3
DAYS AGO WHEN HE DEVELOPED FEVER THAT
WAS SUDDEN IN ONSET, INTERMITTENT,HIGH
GRADE RELEIVED BY MEDICATION FROM
LOCAL DOCTOR.NO H/O RIGORS CHILLS AND
NIGHT SWEATS

5. FEVER WAS ASSOCIATED WITH SORE THROAT
AND PRESENCE OF PAINFUL DISCRETE
SWELLINGS IN NECK.BECAUSE OF THESE
SWELLINGS PATIENT FELT DIFFICULTY IN
SPEAKING,EATING SOLIDS AND MOVING HIS
NECK FROM SIDE TO SIDE

6. NO HISTORY OF
 HEADACHE
 PHOTOPHOBIA
 VOMITTING
 NECK RIGIDITY
 EAR DISCHARGE
 RETERO ORBITAL PAIN
 BODYACHES
 BLEEDING FROM ANY SITE OR RASH ANYWHERE
ON BODY

7. NO HISTORY OF
 DIARRHEA
 CONSTIPATION
 FLANK PAIN
 BURNING MICTURATION
 DARK COLOURED URINE
 HAEMATURIA

8. PERSONAL HISTORY
 SMOKER-VE
 ADDICT-VE
 DM –VE
 HTN –VE
 ASTHMA-VE
 TB-VE
 CONTACT WITH TB-VE

9. PAST HISTORY
 NO HISTORY OF PREVIOUS ADMISSION IN
HOSPITSL OR ANY SERIOUS ILLNESSS

10.  FAMILY HISTORY INSIGNIFICANT
 DRUG HISTORY INSIGNIFICANT
 NO H/O BLOOD TRANSUFION IN LIFE

11. DIFFERENTIALS
 INFECTIOUS MONONUCLEOSIS
 PERITONSILLAR ABSCESS
 LYMPHOMA
 ENTERIC FEVER

12. GENERAL PHYSICAL EXAMINATION
A YOUNG BOY WELL ORIENTED IN TIME PLACE
AND PERSON WITH GCS 15/15
WITH VITALS
BP 110/70 mm hg
PULSE 90/MIN
TEMP 101
R/R 17/MIN

13. GENERAL PHYSICAL EXAMINATION
 PALLOR –VE
 CYANOSIS-VE
 CLUBBING-VE
 LEUKONYCHIA-VE
 KOILONYCHIA-VE
 JVP NOT RAISED
 NO RASH ON THE BODY

14. GENERAL PHYSICAL EXAMINATION
 PALLOR –VE
 CYANOSIS-VE
 CLUBBING-VE
 LEUKONYCHIA-VE
 KOILONYCHIA-VE
 JVP NOT RAISED
 NO RASH ON THE BODY

15. EXAMINATION OF NECK
 B/L PAINFUL DISCRETE FIRM OVAL 2X2 ANTERIOR
CERVICAL LYMPH NODES WITH NO PURULENT
DISCHARGE
 NO OTHER LYMPH NODES PALPABLE
 AXILLARY LYMPH NODE –VE
 INGUINAL LYMPH NODES-VE

16. EXAMINATION OF ORAL CAVITY
 INSIGNIFICANT
 PALATAL PETCHIAE-VE
 APTHOUS ULCERS –VE
 CANDIDIASIS-VE
 GUM BLEED-VE
 GINGIVITIS-VE

17. GIT
INSPECTION
ABDOMEN FLAT ,MOVING WITH RESPIRATION
UMBILICUS CIRCULAR AND INVERTED
NO VISIBLE PULSATIONS,STRIAE,SCAR MARKS
OR PROMINENT VEINS
HERNIAL ORIFICES INTACT
PALPATION
 TENDERNESS IN LEFT HYPOCHONDRIUM
 SPLEEN PALPABLE 2 FINGER BREADTH
BELOW COSTAL MARGIN

18.  NO OTHER VISCERA PALPABLE
PERCUSSION
 FLUID THRILL –VE
 SHIFTING DULNESS -VE
 AUSCULTATION
BOWEL SOUNDS +VE
NO BRUIT OR FRICTION AUDIBLE

19. CVS
 INSPECTION
 PRECORDIUM IS OF NORMAL SHAPE AND NO
VISIBLE PULSATIONS OR SCAR
 PALPATION
 APEX BEAT IN 5TH INTERCOSTAL SPACE MEDIAL
TO MIDCLAVICULAR LINE ,OF NORMAL
CHARACTER. NO OTHER SOUND PALPABLE
 AUSCULTATION
 BOTH HEART SOUDS OF NORMAL INTENSITY
 NO ADDED SOUNDS OR MURMUR

20. RESPIRATION
INSPECTION
RESPIRATORY RATE OF 16/min SHAPE
NORMAL,ABDOMINOTHORCIC TYPE OF
RESPIRATION,B/L EQUAL MOVEMENT
PALPATION
TRACHEA CENTRAL, NO TENDERNESS OR
CREPITUS,EQUAL MOVEMENT ON BOTH
SIDES,EXPANSION OF CHEST IS 3cm
PERCUSSION
UPPER BORDER OF LIVER IN 5TH INTERCOSTAL SPACE

21. AUSCULTATION
BREATH SOUNDS VESICUAR AND OF NORMAL
INTENSITY,NO ADDED SOUND,VOCAL
RESONANCE EQUAL ON BOTH SIDES

22. INVESTIGATIONS
 HB------10.7
 WBC ---25.1×10³
 RBC---381×10⁶
 RBC DISTRIBUTION WIDTH—45.5
 PLATELET COUNT -----212×10³
RED CELL INDICES
HCT……34.9%
MCV…….91.6fl
MCH………28.1pg
MCHC……..30.7g/dl

23. • DIFFERENTIALS
NEUTROPHILS………89.2%
LYPHOCYTES…9.4%
 IMMATURE CELLS
 METAMYLOCYTES –VE
 MYLOCYTES ------------VE
 PROMYLOCYTES –VE
 BLAST CELLS -VE

24. LFTS
 BILIRUBIN----0.8
 ALT—33
 AST---27
 ALKALINE PHOSPHATASE—215
 TOTAL PROTEIN –6.8
 ALBUMIN---3.6

25. RFTS
 BLOOD GLUCOSE ---100 mg/dl
 UREA-------23
 SERUM CREATININE------0.6
ELECROLYTES
• SODIUM------135
• POTASSIUM-----3.5

26. HETEROPHIL ANTIBODY TEST -VE

27. URINE COMPLETE
 SPECIFIC GRAVITY-----1.02
 PUS CELLS ---1 -2
 RBCS –--nil
 PROTEINS--------nil
 KETONES—nil

28.  Call to ENT department was written regarding patients
assesmnt.ACCORDING TO THEM THERE IS NO
ISSUE RELATEDTO EAR NOSE AND THROATT

29.  CHEST X RAY ------NORMAL

30. CASE SUMMARY
 A YOUNG BOY PRESENTED WITH ACUTE H/O
 FEVER ,SORE THROAT ,PAINFUL DISCRETE
CERVICAL LYMPH NODES IN NECK WITH NO
OTHER LYMPH NODES PALPABLE AND TEND
SPLEENOMEGALY.PERIPHERAL BLOOD PICTURE
SHOWED NEUTROPHILIA

31. Question
 Why patient has neutrophilia?
 Why patient has painful spleenomegaly?
 What other investigations we should go for?
 What can be the management policy