60 M with hydrocele associated with Anemia
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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
A 60 year old male resident of suryapet district came to opd with chief complaints of swelling in scrotum since 15 years and blood in urine since 2 months
History of presenting illness:
Patient was apparently asymptomatic 15 years back then he developed swelling in the scrotum after trauma(while lifting the lorry back door, he slipped and got injured during this) the swelling was sudden in onset gradually progressive painless( the reason why he ignored the swelling) not associated with any relieving and aggravating factor
Patient was apparently asymptomatic 2 months back. Then he noticed blood in urine, which was insidious in onset gradually progressive also he has increased frequeny of urine which was increased during night almost every 20-25 minutes. The urine was red in colourtg the following thing was observed by the patient During urination patient first passes red colour urine and then the urine stops for a few seconds then later he passes black coloured clots with burning sensation.
No H/O fever, cough and cold.
No H/o orthopnea and paroxysmal nocturnal dyspnea.
No H/O nausea, vomiting, loose stools and constipation.
No H/O abdominal distension, abdominal pain.
PAST HISTORY:
history of hydrocele 15 years back as mentioned above
In 2019 his wife got a swelling in the post auricular region for which be came to our hospital
Then he also went for checkup for the swelling in scrotum where our doctors diagnosed it as hydrocele. And suggested to have surgery to be done for it. But he refused to it because he has no money for surgery at that time and his wife just got treated.
During corona time, he again visited our hospital with sufficient money( given by his son). But it was very difficult to do surgery at that time because of high wave period of corona patients in the hospital. Then he went back to his village.
He has 3 daughters and one son, all are married and lives at different places except his son who lives in the same village.
Due to issues between him and his son in law family A case was filed against him and then due to this the management removed him from his job.
From then he was staying at home with no specific job, but went to some contracted works in farming fields.
No H/O HTN, diabetes, asthma, epilepsy, TB.
No H/O any past surgery.
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 malunuion
PERSONAL HISTORY:
Appetite: normal
Sleep: inadequate
Bowel and bladder: regular
Addictions: alcohol intake 90ml per day since 38 years stopped since 2 months.
Smoking daily 10 beedi(2 days 1 packet) from 38 years, stopped from 2 months.
Daily schedule :
Wake up at 6 am
Breakfast(idli/ dosa)
work if any or rest
12PM lunch (Rice+ curry( veg/ non veg)+ dal )
Afternoon rest
Evening walking and talking with his neighbours
8 pm ( dinner)
10 pm dinner
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
Clubbing: absent
Cyanosis: absent
Lymphadenopathy: absent
No oedema
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(Done during childhood)
Swelling in scrotum
No visible peristalsis, pulsations, sinuses, engorged veins.
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