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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 :
Hematuria since 2 months
Constipation since 6 days
HOPI :
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.
He also has history of burning micturition and suprapubic pain while passing urine.
Patient also has compliants of constipation since 6 days.
H/o giddiness.
H/o tremors .
No H/O fever, cough and cold.
No H/O nausea,vomiting,loose stools.
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 incident 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.
Not a k/c/o HTN, diabetes, asthma, epilepsy, TB.
No H/O any past surgery.
He has a 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: constipation since 6 days
Addictions:
Alcohol intake every day (90ml) from 30 years, stopped 2 months back.
Smoking daily 20 beedi in 1 day 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 heard
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.
DIAGNOSIS:
Severe Anemia secondary to blood loss (Hematuria)
? Urothelial malignancy with right sided vaginal hydrocele .
INVESTIGATIONS:
16.06.23
Hemogram
Haemoglobin - 5.1gm/dl
Total count - 9000 cells/cumm
Lymphocyte-22 %
Neutrophils-68%
Eosinophils- 10%
Basophils- 00%
Pcv- 16.2 vol%
MCV-77.7fl
MCH -24.3 pg
MCHC-31.3 %
RDW-CV - 27.1 %
RDW-SD - 78.1 fl
RBC count - 2.08 millions/cumm
Platelet count - 3.63 lakhs/cu.mm
2D ECHO
Left ventricle- no RWMA mild LVH positive
EF - 63%
Conclusion:
Mild TR with PAH ,trivial AR, no MR
No RWMA, No AS/MS, Sclerotic AV
Good LV systolic function
Diastolic dysfunction present
No PE/LV clot
Hemogram
Haemoglobin - 5.5gm/dl
Total count - 11,100 cells/cumm
Lymphocyte-30 %
Neutrophils-65%
Eosinophils- 0%
Basophils- 00%
Pcv- 17.6 vol%
MCV-77.4fl
MCH -23.9pg
MCHC-30.9%
RDW-CV - 27.2 %
RDW-SD - 78.8 fl
RBC count - 2.28 millions/cumm
Platelet count - 2.5 lakhs/cu.mm
Haemoglobin - 5.0gm/dl
Total count - 9700 cells/cumm
Lymphocyte-24%
Neutrophils-65%
Eosinophils- 1%
Basophils- 00%
Pcv- 16.2 vol%
MCV-80.5fl
MCH -23.8pg
MCHC-29.6 %
RDW-CV - 20.1 %
RDW-SD - 60.4 fl
RBC count - 2.10millions/cumm
Platelet count - 2.5 lakhs/cu.mm
CUE
Colour - reddish
appearance- clear
ALBUMIN - +++
Sugars - nil
Pus cells - nil/HPF
Epithelial cells- nil HPF
Red blood cells- loaded
15.06.23
Review usg
E/o 6.0*6.0 I'll defined ,hyperechoic lesion with micro calcification noted arising from the posterior wall of urinary bladder with internal vascularity .
F/s/o Urothelial malignancy
14.06.23
USG
LIVER - Normal
Gall bladder - contracted
Pancreas - normal
Right kidney-9.7x 4.1cm -normal
Left kidney -9.5x4.2 cm -normal
AortaIVC- normal
No ascitis
No lympadenipathy
Urinary bladder-empty,wall thickness normal
Prostate- pelvis could not be asseced
Spleen - 8.2cm
Findings-
- spleen is showing multiple hyperechoic foci
-S/O gamma gland bodies
ECG
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
16.06.23
Referral to Urology
A 60yr old patient with right gross vaginal hydrocele with severe Anemia underwent for multiple blood transfusions having 5.0 hb percentage referred to Urology I/v/o hematuria.
Patient complains of gross hematuria since 4 months, painless hematuria present along with tissue bits.
No fever
No pyuria
Burning micturition present
Dysuria present
No previous surgeries
No comorbities
H/o 44 yrs of smoking with h/ of alcoholism
O/E
PT is c/c/c
Afebrile
Vitals - bp -100/60mmhg
-PR -72bpm
- RS - NAD
- CVS- NAD
-PA-NAD
Patient is advised for CECT KUB
Advice :
Improve general condition
Transfusions
Tab.oflox 200 PO BD
Tab. Tranexa 500 PO BD
Tab.Pan 40 PO OD
Tab.Limcee PO OD
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