45 years old male with Inguino Scrotal swelling since 1year , Pancytopenia secondary to Hyper splenism.

1st June,2023


This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.



This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


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


The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 




CASE :-


A 45 years old male who is CHEF by occupation ,resident of Nalgonda came to the opd with Chief complaints of


C/o Right side Inguino Scrotal swelling since 1year


HISTORY OF PRESENTING ILLNESS:-


Patient was apparently asymptomatic 1year back then he started noticed swelling in the Inguino Scrotal region which was insidious in onset , Gradually progressive to present size, cough impulse present, pain over the swelling on prolonged standing .For routine investigations patient was accidentally found to have low platelet count, splenomegaly with dilated portal vein(?PHTN).


No C/o fever, vomitings, pain abdomen

No C/o Loose stools, melena, Bleeding tendencies

No c/o Hematemesis ,Rash

No c/o decreased urine output ,Burning micturition.

No c/o chest pain, palpitations,SOB, orthopnea,PND.



PAST HISTORY :-


N/k/c/o HTN,DM , Asthma,TB,Epilepsy,CVA,CAD


No past surgical history.


PERSONAL HISTORY :-



Marital status : married 


Diet : mixed 

Appetite : normal

Bowel and bladder: regular

Sleep : adequate


Addictions : 


He is a smoker (3-4 beedies per day) since 20years.


GENERAL EXAMINATION:-


Patient was concious coherent cooperative well built and nourished , well oriented to time place and person  at the time of presentation.

Pallor : absent 

Icterus : absent

Cyanosis : absent 

Clubbing  : absent

Lymphadenopathy : absent 

Edema : absent

Vitals 

Temperature : 98.2F

PR : 86bpm

BP : 110 / 80 mm Hg

RR : 14 cpm

Spo2: 98 on RA

GRBS : 105 mg/dl









SYSTEMIC EXAMINATION:-

I) Per Abdomen :

INSPECTION :-

Shape of abdomen -Obese
Umbilicus - inverted
No scars, sinuses, straie
No visible pulsations & visible peristalsis
Movements of all 4 quadrants moving equally with respiration





PALPATION :-
All inspectory findings are confirmed
No local rise of temperature
No Tenderness
Splenomegaly present -4Fingers width from the costal margin.
No hepatomegaly
No palpable lymphadenopathy
Hernial orificies - Free

PERCUSSION :-
No signs of fluid thrill & shifting dullness
Resonant note heard (except liver dullness)

AUSCULTATION :-
Bowel sounds present
No bruit heard

CNS:-

HIGHER MENTAL FUNCTIONS:
Oriented to time place and person 
Immediate memory:Intact
Short term memory:Intact
Longterm memory:Intact
No delusions and hallucinations.

Motor system
Power:-

Rt UL - 5/5 Lt UL-5/5

Rt LL - 5/5  Lt LL-5/5

Tone:-

Rt UL - normal

Lt LL- normal

Rt LL- normal

Lt LL- normal



Reflexes: 

                   Right                    Left

Biceps:      ++                    ++

Triceps:       ++                  ++

Supinator:  ++                   ++

Knee:         ++                    ++

Ankle:            + +                 ++


Plantar:      flexor.         Flexor



CVS:-

S1S2 heard,no murmurs.

Respiratory system examination

Bilateral air entry present.

Normal vesicular breath sounds present.

INVESTIGATIONS:-



Hemogram

1/6/23




    

2/6/23

















    
3/6/23






Provisional Diagnosis:-

Rt sided Inguinal Hernia with bowel as content


 Pancytopenia secondary to hypersplenism


TREATMENT:-


1/6/23



1. INJ.OPTINEURON 1amp in 100mlNS IV/OD


2. BP/PR/RR/TEMP CHARTING 4TH HOURLY


2/6/23


1.INJ.OPTINEURON 1amp in 100mlNS IV/OD


2. BP/PR/RR/TEMP CH

ARTING 4TH HOURLY


Comments

Post a Comment

Popular posts from this blog

19 year old male with fever and lower back pain

Image
19 Year old male with fever and lower backache December 01,2022  This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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 This is a case of 19 year old male from mirylaguda who is intermediate second year student came to general medicine OPD with chief complaints of :
Read more

A 45 YEAR OLD FEMALE WITH PARAPARESIS SECONDARY TO TRAUMA ASSOCIATED WITH DYSPHAGIA

Image
C/O Generalized weakness of lower limbs since 10 years Difficulty in swallowing since 15 days  HOPI: Pt was apparently asymptomatic till 1999  then she delivered a baby(by c-section due to cord entanglement)  she also stated that she started  developed Generalized weakness ( due to low haemoglobin levels ) not associated with pain and was able to perform her daily activities Her husband also left as she couldn't perform her daily activities.Her son currently stays in the hostel   She previously used to work as mandal officer. And in 2012 she stopped going to work because she started developing weakness  insidious in onset , gradually progressive , associated with pain , Aggrevated with walking and relieved with rest. she could not walk for long distances and she managed to  to perform  daily activities In 2023 Jan she alleged had h/o slippage in bathroom following which she was normal for 5 days  Next day she couldn't get up from bed which is sudden in onset and non progressive
Read more

A 25 YEAR OLD MALE PATIENT WITH YELLOWISH DISCOLORATION OF EYES AND URINE, ABDOMINAL DISTENSION AND SOB

Image
 A 25 year old male who is a resident of yadagirigutta Mason by occupation came to casualty with chief complaints of :  *DISTENSION OF ABDOMEN SINCE 6 DAYS  *SHORTNESS OF BREATH SINCE 6  DAYS   *YELLOWISH DISCOLORATION OF EYES AND URINE SINCE 6 DAYS  •HISTORY OF PRESENTING ILLNESS  : Patient is apparently asymptomatic 3 months ago he then developed abdominal distension which is insidious in onset and gradually progressive associated with shortness of breath 3 months back which is of grade 2 and it progressed to grade 3 over 3 months .He also has yellowish discoloration of eyes and urine 6 days back .He also has similar complaint 4 months ago for which he took herbal medication for a week and the symptoms subsided and  he also  stopped drinking for 7 days after that he continued drinking .He also complaints of fever 3 months back which is intermittent which is not associated with chills and rigors for 2- 3 days  And cough which is non productive 10 days back .  Vomiting 2to 3 episodes p
Read more