A 14 YEAR OLD MALE CAME WITH MASS ABDOMEN.

This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.


CASE SHEET:

Chief complaints:

A 14 year old, student, came with:
- mass abdomen since 15 days
- pain abdomen since 1 week

History of present illness:

The patient was apparently asymptomatic 5 months back. He then developed pain abdomen on left side, which is of dragging type, non radiating, no aggravative or relieving factors.

He also had similar complaints in the past3 months back, and  was diagnosed to have spleenomegaly and cervical lymphadenopathy.

No history of vomitings 
No history of lose stools.

Past history:

- History of similar complaints 3 months back and diagnosed with spleenomegaly.
- Not a known case of Diabetes mellitus, Hypertension, epilepsy, coronary artery disease.

Personal history:

Diet: Mixed
Bowel : regular
Micturition: normal
Appetite: Decreased
Habits: nil
No history of allergy, asthma, tuberculosis, coronary artery disease.

Family history:
Insignificant

GENERAL EXAMINATION:

No pallor 
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No dehydration
No pedal edema

VITALS:

Temperature: 97.4 F

Pulse: 82 beats per minute

Respiratory rate: 16 cycles per minute

Blood pressure: 110/70 mm of Hg

SPO2: 96%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills
murmurs: systolic murmur
Cardiac sounds: S1, S2 heard

Respiratory system:

No dyspnea 
No wheezing
Breath sounds heard: vesicular

Abdomen:

Shape of abdomen: scaphoid
No tenderness
Palpable mass
Non palpable liver
Palpable spleen - spleenomegaly
No bruits
Bowel sounds: heard

Central Nervous System:

Conscious
Speech: normal

Investigations:

USG:

ECG:

Provisional Diagnosis:
Spleenomegaly secondary to portal hypertension.

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