A 77 year old male with Splenomegaly

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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.

DOA: 07/11/2023

CHIEF COMPLAINTS:

The patient presented to the OPD with the chief complaints of -

- Lower abdominal pain since 10 days 

- Bilateral pedal edema since 3 years 

HOPI:

The patient was apparently asymptomatic 10 days ago and then he developed pain in the lower abdomen which is sudden in onset, non radiating, dragging type, no aggravating factors, relieved temporarily on medication.

The patient also complains of bilateral pedal edema of pitting type since 3 years which occurs on prolonged sitting and relieved at night on lying down in supine position with legs elevated. The patient also mentions that he urinates 2 to 3 times during the night following which the pedal edema is relieved. This urge to urinate multiple times at night leads to disturbance in his sleep. 

No h/o SOB, orthopnea, PND, palpitations, giddiness, fever, diarrhea, constipation, lower urinary tract symptoms, discolorations of urine or stools, bleeding manifestations 

PAST HISTORY:

K/c/o Hypertension since 5 years, using Amlodipine 5mg and Atenolol 50mg

Pt complained of pain in right upper abdomen 7 years ago and was diagnosed with Cholelithiasis, underwent Cholecystectomy 

N/k/c/o DM, Asthma, TB, Epilepsy, CAD, CVD

PERSONAL HISTORY:

The patient wakes up at 5:00am and finishes his morning chores such as brushing, bathing and breakfast. His occupation is animal husbandry and business involving farm animals. His job involves him travelling often on the bike and in the bus during which his pedal edema is exacerbated. He sleeps at around 9:00pm daily. His sleep is disturbed due to urge to urinate multiple times during the night.

His diet is mixed, appetite is normal and bowel and bladder movements are regular 

GENERAL EXAMINATION 

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

He is well-built and nourished 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema 

Vitals on admission - 

Temp - Afebrile 

BP - 120/80 mm hg 

PR - 78bpm 

RR- 18cpm 

SYSTEMIC EXAMINATION:

I’m 

CVS:  S1, S2 heard , no murmurs 

CNS:  NAD 

RS:  B/L air entry + , trachea central , NVBS heard 

P/A : obese, midline scar present, soft, non tender

Splenomegaly present, spleen palpable 4-5cm below the costochondral margin

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

?Tropical Splenomegaly  

TREATMENT: 

Inj ARTESUNATE 180mg

Inj MULTIVITAMIN 1amp in 100ml NS OD

Tab SHELCAL  PO/OD

Monitor vitals and inform SOS