A 45 year old male patient with abdominal pain due to hernia and palpable spleen since 15 days - GM CASE 10

4th June 2023
CASE STUDY 10

Hello, I am Saloni .S. Gangotri , a 5th semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.

CASE SHEET:

CHIEF COMPLAINTS:
c/o 
- Lower abdominal pain and swelling in inguinoscrotal region since 15 days.


HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 15 days ago until he noticed a swelling on right inguinoscrotal region. It started to pain on doing any activity, was gradual in nature, intermittent and relieved on rest. Cough impulse was present.

No h/o vomiting, nausea, fever, diarrhea, constipation, burning micturition, rash, bleeding, palpitation. dyspnea or chest pain.


ASSOCIATED DISEASES:

———


PAST HISTORY:

No K/C/O DM, HTN, Epilepsy, TB, CAD. 


PERSONAL HISTORY:

Married since 2003.
Is on a mixed diet.
Normal appetite.
Adequate sleep.
Regular Bowel movements. 
Has no known allergies.

Smokes 1 pack of cigarette per day since 15 years.



FAMILY HISTORY:

Has N/K/C/O  Diabetes Mellitus, No HTN, No Strokes, No cancers. No CAD, TB, Asthma or Epilepsy.


DRUG HISTORY:




GENERAL EXAMINATION:

-No palor
-No Icterus
-No cyanosis 
-No lymphadenopathy
-No pedal edema
-No clubbing of fingers



VITALS:

Temperature: Afebrile - 98.2°F

Pulse: 86 beats per minute

Respiratory rate: —18 cycles per minute

Blood pressure: 110/70 mm of Hg

SPO²: 100%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills
No murumurs
Cardiac sounds: S1, S2 present 

Respiratory system:

No dyspnea
No wheezing
Breath sounds heard: vesicular? yes

Abdomen:

Shape : Obese
No tenderness
No palpable mass
Palpable spleen
Hernia present 
Non palpable liver
No free fluid (ascites) present 
No bruits
Bowel sounds: heard


Central Nervous System:

Conscious and Alert 
Speech: Normal

INVESTIGATIONS:
Biochemical investigations:



ECG:


2D-ECHO REPORT:

——


ULTRASOUND REPORT:




GRAPHIC SHEET :

——



PROVISIONAL DIAGNOSIS:
———






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