75 yr old male resident of Guntur came with chief complaint of scrotal swelling since 2 weeks and reduced urine output since 2 days

 Hi, I am Presley C (roll no :96), 5rd semester medical student. This is an online E-log book to discuss our patient’s health data after taking his consent. This also reflects my patient-centered online learning portfolio.

A 75years male resident of  Guntur admitted with chief complaint of scrotal swelling since 2 weeks and reduced urine output since 2days.

He is a Known case of heart failure with preserved ejection fraction.

Chief complaints 

A 75years male resident of  admitted with chief complaint of scrotal swelling since 3 days and reduced urine output since  1 day

Known case of heart failure with preserved ejection fraction with anemia

Chronic kidney disease 4 stage secondary to diabetic nephropathy 

Known case of diabetes mellitus type 2

SOB grade 2

Pedal edema  with pitting type since 2 months 

History of present illness

No history of trauma,fever.

Generalised edema since 3 months

History of decreased  urine output since 1 day

No history of nausea, vomiting,constipation,loose stools .

 History of past illness

Known case of type 2 diabetes mellitus since 10 yrs

Medication :

Not a know case of HTN,THYROID,CAD,CVA,TB,epilepsy 

No previous surgery

PERSONAL HISTORY

Married

Occupation works as labourer

Diet:mixed

Appetite:normal

Bowel movement:regular

Micturation:abnormal decreased output since 1 day

Sleep:normal

No known allergies

HABITS

alcohol:regular since 40 yrs

Tobacco: Chutta 10 per day since 40 yrs

FAMILY HISTORY 

 Not significant 

GENERAL EXAMINATION 

No pallor 

No icterus 

No cyanosis 

No clubbing of fingers

No lymphadenopathy 

 pedal odema 

REFLEXES

Biceps :++

Triceps :++

Supinator :++

Knee :++

Ankle :++

CERBEILAR SIGNS

Finger nose in coordination 

Knee heel in coordination 

SYSTEMATIC EXAMINATION:

B. CARDIO VASCULAR SYSTEM

1. Thrills No 

2. Cardiac Sounds 

3. Cardiac murmurs No 

C. RESPIRATORY SYSTEM

1. Dyspnoea - no

2. Wheeze - No 

3. Position of Trachea - Central

4. Breath Sounds - 

5. Adventilious Sounds - 

D. ABDOMEN

1. Shape of abdomen -Obese

2. Tenderness - No

3. Palpable mass - No 

4. Hernial Orifices Normal 

5. Free Fluid : No

6. Bruits No 

7. Liver - Not palpable

8. Spleen - Not palpable 

9. Bowel sounds -Yes

10.Genitals normal

CENTRAL NERVOUS SYSTEM 

1.level of conscious:conscious and covert

2.speech:normal

3.sign of menningeal irritation

Neck stiffness no

Kerning sign no

4.Cranial nerve normal

5.Motor system normal

6.sensory system normal

7.Glasgow Scale normal

SCROTAL REGION

on inspection 

Swelling of scrotal area of about size 15*10 cm

Involves whole of scrotum including penis

Skin over the swelling distended

Surface appeared to be smooth

Discharge positive 

Blebs positive

No visible pulsation

No visible cough impulse

On palpation

No local rise of temperature 

No tenderness

Soft in consistency

Pitting edema positive

No reducible

Investigation 

USG-abdomen

Complete Blood Picture

Liver function test

Renal function test

PROVISONAL DIAGNOSIS:

Scrotal wall edema? with congestive heart failure