Case 9 A 45 year old man with right inguinal hernia and thrombocytopenia secondary to splenomegaly

A 45 year old man with right inguinal hernia and thrombocytopenia secondary to splenomegaly

Hi, I am R. Ramya Keerthana, 5th semester medical student. This is an online elog book to discuss our patients health data after taking their consent. This also reflects my patient centered online learning portfolio.

Case Scenario
A 45 year old man from Nalgonda came to OPD on 1st of June with chief complaints of:
- swelling in the right lower abdomen since 3 months 
- pain pain over the swelling since 15 days.

History of Presenting Illness
- patient was apparently asymptomatic 3 months ago when he noticed a swelling in the right inguinal region which is insidious in onset and gradually progressed to present size
- he then developed  pain over the swelling 15 days ago which is sudden in onset, gradually progressive, intermittent and of pressing type
- pain is aggravated on  exertion and relieved on rest 
- no h/o fever, nausea, vomiting, diarrhea, constipation, melena, bleeding, hematemesis, rashes, shortness of breath
- no h/o burning micturition, reduced urine output
- routine investigations found the patient to be having a low platelet count and splenomegaly.

Past History
- n/k/c/o hypertension, diabetes mellitus, tuberculosis, CAD, epilepsy, asthma, thyroid disorder
- no h/o surgery 
- no h/o blood transfusions

Personal History
-married
-works as a chef
- mixed diet
- normal appetite
- adequate sleep
- regular bowels
- normal micturition
- no known allergies
- non alcoholic 
- chronic smoker (1pac /day)

Family History
- h/o diabetes mellitus
- no hypertension 
- no heart disease
- no stroke
- no cancer
- no tuberculosis 
- no asthma
- no other hereditary diseases

General Examination
- patient was conscious, coherent and cooperative
- well oriented to time and space
- well built and adequately nourished
- no pallor
- no icterus
- no cyanosis 
- no clubbing of fingers
- no lymphadenopathy 
- no pedal edema
- no malnutrition 
- no dehydration 


Vitals
- BP: 110/70 mm Hg
- Pulse rate: 86 bpm, regular rhythm, normal volume
- Respiratory rate: 18 cpm
- Temperature: afebrile 
- SPO2: 100% at RA
- GRBS: 108 mg/dL

Systemic Examination
Cardiovascular System
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs

Respiratory System
- no dyspnea
- no wheeze
- trachea position: central
- breath sounds: vesicular
- no adventitious sounds

Abdomen
- shape: obese
- no scars, striae, engorged veins
- bowel sounds heard
- no bruits, rubs
- no shifting of dullness
- no fluid thrill
- hernia present 
- liver: not palpable 
- spleen : palpable


Investigations


Treatment

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