A 60YEAR OLD MALE WITH ANAEMIA AND HYDROCOEL


Y.Navya sahithi reddy
Roll no.1701006200
2017 batch
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

A 60 year old male, resident of appalgudathanda suryapet district presented to OPD with chief complaints of hematuria since 2 months.

Chief Complaints :
Patient complains of Hematuria since 2 months
History of Presenting Illness:

Patient was apparently asymptomatic 2 months back. Then he noticed blood in urine, which insidious in onset, gradually progressive. Increased in frequency of urine, mainly during night times for every 20 min(40-50ml) which is 
red in colour. Incontinuity of urine is present, at first patient passes red colour urine along with passage of black coloured clots with burning sensation.

H/O tremors

No H/O fever, cough and cold.

No H/O nausea,vomiting,loose stools and constipation 

No H/o orthopnea and paroxysmal nocturnal dyspnea.

No H/O abdominal distension, abdominal pain.

Past history:

History of hydrocele, since 15 years.

He worked as a lorry driver for 20 years.

History of trauma 15 years back, while lifting the lorry back door, he slipped and fell during this. 

After this incindent in 1-2 months he noticed a swelling in the right groin which is gradually increased in size, painless. Later he neglected the swelling as there was no pain.

No H/O HTN, diabetes, asthma, epilepsy, TB.

No H/O any past surgery.

H/O fracture of left humerus at distal end, when he was 20 years old, while cutting a tree. Then he got treated for it with reduction and plaster of Paris. But the treatment resulted in malunion.

PERSONAL HISTORY:

Diet: mixed

Appetite: normal

Sleep: adequate

Bowel and bladder: regular

Addictions: alcohol intake every 2 days (90ml)from 30 years, stopped 2 months back

Smoking daily 10 beedi(2 days 1 packet) from 30 years,stopped 2 months back 


FAMILY HISTORY:

No significant history.


GENERAL EXAMINATION:

Patient is conscious, coherent, and co-operative. Well oriented to time place and person.

He is moderately built and moderately nourished.

Pallor- present

Icterus- absent

Cyanosis- absent

Clubbing- absent

No lymphadenopathy

No edema

VITALS:

Temperature- Afebrile

Blood pressure- 120/80mm hg

Pulse rate- 96bpm

Respiratory rate- 20cpm

SYSTEMIC EXAMINATION:
Per abdomen: 
On inspection:

Shape of abdomen: scaphoid

Umbilicus: inverted

Movements of abdominal wall with respiration

Scars present( due to beliefs that it helps in digestion, done in childhood)

Swelling in scrotum.(hydrocele?)

No visible peristalsis, pulsations, sinuses, engorged veins.
On palpation:

No local rise of temperature 

Inspectors findings are confirmed

Soft and non tender

No palpable masses

Liver is not palpable

Spleen is not palpable
On percussion:

Resonance note heard

On auscultation:

bowels sounds heardSoft and non tender

No palpable masses

Liver is not palpable

Spleen is not palpable

CVS examination:

Inspection:

No raised JVP

Trachea appears to be central

The chest wall is bilaterally symmetrical 

No dilated veins, scars or sinuses are seen

Palpation:

Trachea central in position 

Apex beat is felt in the fifth intercoastal space, 1cm medial to the midclavicular line

Auscultation:

S1 S2 heardNo murmurs 

Respiratory examination:

Shape of chest is elliptical, bilaterally symmetrical

B/L airway entry positive

Normal vesicular breath sounds

CNS Examination:

Conscious 

Normal speech.

No neurological deficit found.

PROVISIONAL DIAGNOSIS:

Anemia under evaluation

Hematuria?
INVESTIGATIONS:

12-06-2023

Complete Blood picture:

HAEMOGLOBIN 4.2 gm/dl

TOTAL COUNT 9,750 cells/cumm

NEUTROPHILS 63 %

LYMPHOCYTES 28%

EOSINOPHILS 01%

MONOCYTES 08%

BASOPHILS 0%

PLATELET COUNT 4.0 lakhs /cumm


SMEAR Normocytic normochromic anemia



Prothrombin Time 16 sec


INR 1.11

BLOOD GROUP-O

RH TYPING -POSITIVE (+VE)

BLEEDING TIME - 2 Min 00 sec

CLOTING TIME - 4 Min 00 sec

APTT TEST- 32 Sec


Complete Blood Picture done on 13-6-23:

HAEMOGLOBIN 3.6 gm/dl

TOTAL COUNT 7,300 cells/cumm

NEUTROPHILS 60 %

LYMPHOCYTES 30%

EOSINOPHILS 00%

MONOCYTES 10%

BASOPHILS 0%

PLATELET COUNT 3.2 lakhs /cumm

SMEAR Normocytic normochromic anemia




USG IMPRESSION:

Spleen is showing multiple hyperechoic foci

S/O gamma gandy bodies 

Final diagnosis
 Severe anaemia with hematuria

Questions?
1) WHAT ARE THE CAUSES FOR ANAEMIA?
2) WHAT ARE THE TYPES OF ANAEMIA SEEN?
3) HOW IS THE ANAEMIA GRADED?
4) WHAT ARE THE CAUSES OF HEMATURIA?
5) WHAT ARE TYPES OF HEMATURIA SEEN? 








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