A 72 YEAR old male with anemia

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 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.  

A 72 year old male,a retiree came to opd with chief complaints of  shortness of breath since 1month and pedal edema since 1month .and constipation since 1month

HOPI: Patient was apparently asymptomatic 5 years ago ,then he developed constipation and blood in stools which is bright red stained ,he went to near by hospital diagnosed as grade 2 hemorrhoids subsided by medication.

on 16 June 2022 ,he insidiously found yellowish discoloration in palms and has facial edema sudden in onset  and b/l pedal edema upto midpart of leg,pitting type , insidious in onset and gradually progressive, he has decreased appetite and it is associated with nausea, history of not passing stools for 4 days and blood in stools which is bright red stained.he went to hospital ,by cbp he was found to have hemoglobin 4, blood has been transfused associated with chills ,rigor and fever for 2 days ,on 5th July he came to our hospital for shortness of breath aggravated in supine position and relieved on sitting position and associated with wet cough ,white in colour for 7 days.

history of burning micturition from 1 month not associated with fever or hesitancy.

PAST HISTORY: he is a known case of hypertension and diabetes since  6 years and maintained on medication


PERSONAL HISTORY: Before onset of these symptoms ,patient used to wake up at6 am,take medication anti hypertensive and anti diabetic medication, take chai  eats tiffin which is mainly rice ,watches youtube videos ,TV and eats lunch which is with rice and dal and sleeps for some time and goes out,talk to friends eats  rice and curry  for dinner at 7PM and sleeps at 9pm . he passes stools day by day and urinates around 10 times daily and urinates around 5 times at night time . he chews tobacco evening times for past 30 years

He is a driver ,drives tata ace as movers and packers ,around Hyderabad and vijayawada and also long distance for past 40 years and he stopped his work past 2 years

He has a second wife and he has two children two boys ,both are died due to respiratory failure and kidney failure around 20years and 19 years respectively .

GENERAL EXAMINATION: patient is conscious coherent and cooperative, well oriented to time place and person

Pallor present 
















icterus cyanosis clubbing lymphadenopathy absent 

pedal edema present

vitals :

a febrile

BP: 

PR-62bpm

RR-20cpm

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM- 

Patient examined in sitting position

Inspection:-

Upper respiratory tract - oral cavity, nose & oropharynx appears normal. 

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements appear equal on both sides and it's Abdominothoracic type. 

Trachea central in position & Nipples are in 4th Intercoastal space

No signs of volume loss

No dilated veins, scars, sinuses, visible pulsations. 


Palpation:-

All inspiratory findings confirmed

Trachea central in position

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line

MEASUREMENTS-

chest circumference- 31 inches at expiration & 32 inches at full inspiration

Chest expansion- 2.5cm

                                        left             right

Hemithorax-              15.5 inches  15.5 inches

Hemithorax expansion-  1/2inch     1/2inch

AP diameter-                  10 inches

Transverse diameter-    12 inches

AP/T ratio - 0.58


Respiratory movement's:- normal on both side. 


Tactile vocal phremitus- equal in all areas


Percussion:-

                                       Right              left


Supraclavicular- Resonant (R)        (R) 

Infraclavicular-              (R)              (R) 

Mammary-                     (R)                (R)

Axillary-                          (R)                (R)

Infra axillary-             ( R)                  (R) 

Suprascapular-             (R)                 (R) 

Interscapular-               (R)                 (R) 

Infrascapular-           ( R)                  (R) 



Auscultation:-


                                      left         right


Supraclavicular- Normal vesicuLr Breath sounds (NVBS) 

Infraclavicular-          (NVBS)    (NVBS)

Mammary-                 (NVBS)      (NVBS)

Axillary-                      (NVBS)     (NVBS)

Infra axillary-      (NVBS)           (NVBS)  Suprascapular-          (NVBS)     (NVBS)

Interscapular-         (NVBS)       (NVBS)

Infrascapular-         (NVBS)       (NVBS)

ABDOMINAL EXAMINATION


INSPECTION

➤Shape - Scaphoid, with no distention.

➤Umbilicus  - Inverted

➤Equal symmetrical movements in all the quadrants with respiration.

➤No visible pulsation,peristalsis, dilated veins and localized swellings.


PALPATION

➤SUPERICIAL :no local raise of temperature and tenderness in left hypochondriac region.

➤ DEEP : massive splenomegaly

➤Abdominal girth : ?

➤xiphesternum to umbilicus distance was equal to umbilicus to pubic distance.


PERCUSSION

➤percussion of spleen

➤Fluid thrill and shifting dullness absent 

➤puddle sign absent

AUSCULTATION

➤ Bowel sounds present.

➤No bruit or venous hum.

NO LOCAL LYMPHADENOPATHY

CVS EXAMINATION:

INSPECTION: JVP raised.

https://youtube.com/shorts/0-uonklZXUs?feature=share

PALPATION:apex beat present on 5th ics 1cm medial to midclavicular line

AUSCULTATION:S1 is louder than S2 in all 4 areas .


INVESTIGATIONS:

CHEST X RAY:




on 17/6/22

on 20/6/22
on 21/6/22
on 2/7 /22
on 4/7/22

LFT
on 17/6/22

on 2/7/22

ECG




Echo findings  are normal

USG ABDOMEN
impression: post void residue significant
diffuse urinary bladder wall thickening with indentations and diverticuli.
Raised echogenecity of bilateral kidney
Spleenomegaly




DIAGNISIS: Pulmonary edema secondary to diastolic heart failure (due to anemia or cld?) 
anaemia secondary to haemarrhoids.

TREATMENT:

IV IRON SUCROSE 200mg in 100ml NS OD
INJ OPTINEURIN 1 amp in 100ml NS IV OD
SITZ BATH with BETADINE TID

OINT ANOBT for la before and after defecation 30mins

ISOPHGLUS GRANULES PERORALLY BD

TAB MONTEX-LC / PO /OD  at 9pm
TAB DOLO 650mg/PO/TID.
 

Is jaundice due to portal hypertension explained by spleenomegaly,then why liver function tests are normal?

why there is hyponatremia and hypokalemia? 

Is anorectal varices are haemarrhoids?
No, it is a common misconception  that both are same .
rectal varices are engorged veins due to Porto systemic collaterals, it causes massive bleeding.
haemorrhoids are prolapse anal cushions(cushion composed of ectatic venular-arteriolar communications of the hemorrhoidal plexus No direct communication of these plexus to portal veins.

How iron deficiency anemia causes spleenomegaly?
IDA is correlated with the incidence of splenomegaly, and the incidence of splenomegaly significantly increases as the severity of IDA increases. This is considered to be caused by extramedullary hematopoiesis










 



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