Case 3 splenomegaly

20 year old male with massive spleenomegaly

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December 19, 2022

I've 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 a diagnosis and treatment plan.

Following is the view of my case: 

Chief complaints: 

20 year male patient came to the casualty with the chief complaints of Neck pain since 2 days

                        Back pain since 2 days

                       Fever since 1 day

                       Blood in urine since 1 day(one episode)

HOPI:

Patient was apparently asymptomatic 2 days back then he developed neck pain which was of dragging type and insidious in onset and gradual in progression ,non radiating and relieved on medication( aceclofenac). It is not associated with vomitings, giddiness, rigidity and loss of consciousness. Back pain was in lower lumbar region and pricking type and was continuous. Fever was insidious in onset, low grade and relieved on medication.

Past history:

Patient had hypospadias and was corrected at 6 years of age.

Patient had facial puffiness and slight edema of lower and upper limbs at 12 years of age and was found to have anaemia and one unit of blood was transfused.

He had history of jaundice 10 days back

Not a known case of diabetes, hypertension, asthma, epilepsy, tb 

Family history: no similar complaints in family

Personal history:

Diet:mixed

He wakes up at 7:30 and eats rice and pickle for breakfast everyday . He takes dal and rice for lunch and curry and rice for dinner. Drinks tea in the evening.

Eats non veg twice a week.

Appetite: normal

Bowel and bladder movements: regular

Sleep :adequate(7-8 hrs)

No addictions

General examination 

Patient is conscious ,coherent and cooperative .well oriented to time, place and person 

Pallor present

Icterus present 

No cyanosis

No clubbing 

No lymphadenopathy 

No oedema

Vitals:

Temperature:98.7 F

Pulse rate: 98bpm

Respiratory rate:19cpm

Bp: 120/80 mmhg

Spo2: 98% on RA

Grbs:152mg/dl

Systemic examination 

Cvs:

S1 S2 present 

No thrills 

No murmurs 

Respiratory system:

Vesicular breath sounds 

Position of trachea is central 

No dyspnoea 

No wheeze 

Abdomen:

Shape of abdomen: scaphoid 

No tenderness 

No palpable masses 

No free fluids 

Spleen: palpable below left coastal margin 

Bowel sounds present 

CNS:

Patient is conscious 

Normal speech 

No neck stiffness 

Glasgow scale 15/15

Reflexes normal 

Investigations 

20/12/22

Hemogram (19/12/22)

Hb: 6.0

Total count: 2,500

RBC:20.6

Platelets: 1.54

Reticulocyte count:0.6%

Serum iron:34ug/dl

Serum electrolytes:

Sodium:132

Potassium :42

Chloride :102

Calcium:0.93

Blood urea:30

Serum creatinine:0.7

Lft:

Total bilirubin:2.51

Direct bilirubin:0.40

Sgot:24

Sgpt:19

Alp:158

Total proteins:6.7

Albumin:4.1

A/g ratio:1.63

LDH:110

Dengue NS1 antigen: negative

Blood for dengue test: IgM : reactive on (18/12/22)

Peripheral smear:

Microcytic hyprochromic anemia with leukopenia

Direct and indirect coombs test: negative

Ecg

Chest x ray

Usg abdomen and pelvis:

Massive spleenomegaly

Size:19.8 cms

Hemogram(20/12/22)

Hb:6.0

Total count:2,200

Rbc:3.82

Platelet count:1.24

Ferritin:5.1

                     X ray skull

X ray c spine

Hemogram (21/12/22)

Hemoglobin- 5.8gm/dl

Total count- 3,000cells/cmm

Neutrophils-40

Lymphocytes- 48

Eosinophils-02

Monocytes-10

Basophils-0

Rbc:3.63

Platelets-1.02 

Smear

Anisopoikilocytosis with microcytes macrocytes ,normocytes,with few target cells and pencil forms.

Hemogram (22/12/22)

Hb:5.8

TLC:2,400

RBC:3.64

Platelet count:1.52

Hemogram (23/12/22)

Hb:5.8

TLC:2,300

Rbc:3.55

Platelet count:1.36

LFT(23/12/22)

Total bilirubin:1.20

Direct bilirubin:0.31

SGOT:20

SGPT:29

ALP:165

Total proteins:5.6

Albumin:3.4

A/G ratio:1.65

Hemoglobin electrophoresis:

Upper GI endoscopy:

Impression:

Atrophic fundal gastritis

Hemogram (24/12/22)

Hb:6.4

TLC: 3,000

Rbc:4.0

Platelet count:1.3

Bleeding time:2 mins 30 seconds

Clotting time:5 mins 00 seconds

APTT:40 seconds

PT:20 seconds

INR:1.4

LFT(24/12/22)

Total bilirubin:1.20

Direct bilirubin:0.31

Sgot:20

Sgpt:29

Alp:165

Total proteins: 5.6

Albumin:3.4

A/g ratio:1.65

Treatment:

19/12/22

Inj. Vitcofol 1500mcg IM/od

Tab hifenac p po bd

20/12/22

Inj. Vitcofol 1500 mcg im/od

Tab hifenac p po bd

Tab pan 40 mg po od

21/12/22

Inj. Vitcofol 1500mcg IM od

Tab hifenac p PO BD

Tab pan 40 mg po od

Inj FCM 500mg in 100ml ns /iv /stat 

Tab pcm 1 gm po sos

22/12/22

Inj. Vitcofol 1500mcg IM OD 

1 Ns @25ml/hr Iv

Inj iron sucrose 200 mg in 100 ml over 1 hr alternate days IV/OD

tab pcm 1gm po/bd

Tab. Pan 40mg po od

Tab. Buscopan po od 

23/12/22

Inj. Vitcofol 1500mcg IM OD 

1 Ns @25ml/hr Iv

Inj iron sucrose 200 mg in 100 ml over 2 hrs alternate days IV/OD

tab pcm 1gm po/bd

Tab. Pan 40mg po od

Tab. Buscopan po bd

24/12/22

Inj. Vitcofol 1500mcg IM OD 

1 Ns @25ml/hr Iv

Inj iron sucrose 200 mg in 100 ml over 2 hrs alternate days IV/OD

tab pcm 1gm po/bd

Tab. Pan 40mg po od

BONE MARROW BIOPSY