69yr old male splenomegaly with leucocytosis

March 5, 2020
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

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

Team:

Interns-Dr.Nagasiva 

             Dr.Ruchitha

             Dr.Nimma siva

PG's - Dr.vaishnavi pgy1

          Dr.sushmitha pgy1

          Dr.praneeth pgy2

C/o abdomen swelling since 2 months ,pain abdomen since 2 months ,fever with rise of temperature during nights since 2 months.
HOPI: patient was apparently asymptomatic 2 months back then he noticed swelling in left side of abdomen which was increasing in size,pain abdomen since 2 months  present in left hypochondrium region which is of dull aching type associated with swelling more clearly present on taking food .Low grade fever daily since 2 months more during nights associated with sweating. H/O malaria one month back diagnosed outside  and has taken medication. No h/o vomiting,loose stools dyspesia,haemetemesis,bleeding per rectum.
PAST HISTORY: patient had a simmilar complaint in the past 5yr back for which he took medication.Not a k/c/o hypertension, diabetes mellitus, epilepsy, bronchial asthma, tuberculosis.
SURGICAL HISTORY:h/o abdominal surgery 10 years back - patient does not know details.
PERSONAL HISTORY: diet- mixed, appetite- normal,sleep - adequate,b&b - regular.
Not a smoker or alcoholic history
No significant family history.
General examination: patient is conscious, coherent, cooperative; moderately built and nourished no signs of pallor, icterus , clubbing ,cyansos, lymphadenopathy , edema.
Abdominal examination:
Inspection : shape of abdomen is distended .moments of left side of abdomen is decreased.vertical scar of 15 cm in midline is present. No engorged veins.
Palpation: No local rise of temperature or tenderness.All inspectatory findings are confirmed.splenomegaly of size 6cm from left coastal margin reaching upto umbilicus.no hepatomegaly.
   
INVESTIGATIONS:
Smear:
serology:
LFT:
RFT:
CBP:
 differential diagnosis: myeloproliferative disorders 
Further investigations required delayed due to covid 19
Treatment: 
Tab.pcm 650mg tid x 5 days
Tab.pan 40 mg od x 3 days
Tab.buscupan 10mg bd x 7 days
Tab.ciprofloxacin 500 mg bd x 7 days
Tab.mvt od x 15 days
Tab.limcee od x 15 days

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