GENERAL MEDICINE CASE DISCUSSION

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

1st June,2023

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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

BGT

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