A 60YEAR OLD MALE WITH ANAEMIA AND HYDROCOEL
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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