GENERAL MEDICINE CASE DISCUSSION

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 Cheif 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

3/6/23
4/6/23


CUE


LFT
Blood urea

Serum creatinine

Serum Electrolytes
Urine protein /Creatinine ratio(3/6/23)

RBS
Serology
2/6/23
FBS

PLBS
Hb1ac
Lipid profile

BT&CT

Aptt

PT&INR
Direct Coombs Test
2decho
Chest x-ray
Usg abdomen (outside report )
24/5/23
usg abdomen
USG inguino scrotum

Ecg
General surgery refferal
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 CHARTING 4TH HOURLY





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