A 40 year old male came to the OPD with Massive splenomegaly, portal hypertension since 5 years, and Nasal cellulitis 1 day

                       GENERAL MEDICINE 

                                      ~Case based discussion 

                                  

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 in the comment box .

         I have been given this case to solve in an attempt to understand the patient clinical data analysis to develop the competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. 

A 40 year old male patient came to the opd with the chief complaint of swelling of since 1 day, fever since 1 day and cold and cough since 10 days.

      Apparently the patient was asymptomatic 10 days ago, later he developed cold and non productive cough, fever associated with post nasal sinus drip which is yellow coloured and odour less.He is also complains of burning type of sensation in left nostril, and says that he occasionally sees blood in his expectorium.

     Yesterday morning, he developed nose swelling which is sudden in onset and gradual in progression, presently covering the entire nose, associated with pain the region of nose, mastoid process and lower jaw. 

Past history: No history of similar complaints in the past.

    Has undergone EVL bandaging 6 times since 2k18 - 2k20

    Suffering with splenomegaly and portal hypertension since 2k18. 

     He says that he constitutes genetic problem of blood thickening.

     He has no H/o hypertension 

                   No H/o Diabetes 

                  No H/o thyroid disorders Treatment History: Uses homeopathy medicine for his liver related issues.

 Personal History: Normal appetite 

                              Adequate sleep

                              Mixed diet.                 

  Burning micturition since 20 years

Family History: Father ( since 2007 ), mother ( since 2020) and brother ( since 2020 ) are known cases of Diabetes. 

General Examination:

 The patient is conscious, coherent, cooperative and well aware of surrounding place and time, moderately built. 

No pallor, icterus, cyanosis, clubbing and lymphadenopathy. 

Vitals :

Temperature: 103.2°F

Blood pressure: 100/60 mm of Hg

Pulse rate: 76 bpm

Respiratory rate: 18 cpm.

Nose is swollen 

Systemic examination: 

Per Abdomen:

Spleen: firm

 Margins : extending from midline 

Size: Almost more than 3 times regular spleen.

Umbilicus: Everted

      He has been reffered to the ENT department where they have made the following diagnosis: Acute Rhinosinusities and massive splenomegaly due to pre hepatic portal hypertension 

Treatment advised :

Tab AUGMENTIN 650mg

Tab PANTOP 40mg

Tab ZERODOL - 5pp

Tab LEAVOCET 5mg

Tab BETADINE GARGLE