Surgery Logbook

Assignment 3
Name: Razeen Riyasat Ali
ID: 20180014
General Data
Name: Pauliasi M***
Age: 78 years old
DOA: 29/6/22
DOB: 09/08/1943
NHN:32********
Sex: Male
Address: Narewa Nadi
Religion: Christian
Chief Complain:
- Testicular swelling
- SOB

HPI:
- The patient presented to the GOPD for review of bloods when he
complained of swelling in his scrotum. According to the patient, he has
been having a fluid overload state for approximately 5 months. He
claims that the testicular swelling has been there for 2 weeks now, due
to which he has difficulty in sitting, walking and urinating.
Review of Systems:
a) Respiratory
(+) occasional cough
(+) dyspnea
(+) Mild Respiratory Distress
(+) SOB
(-) Hemoptysis
(-) Tachypnea
b) Cardiovascular:
- palpitations
+ syncope
+ chest heaviness
- chest pain

c) Gastrointestinal:
Normal Bowel Output
(-) Diarrhoea/ constipation
(-) hematochizia
(-) vomiting
Genitourinary:
(+) dysuria

CNS:
(-) seizures
(-) Ataxia

Musculoskeletal:
-Nil
Skin:
-Nil
Past Medical History:
- K/C/O CCF, HTN, fluid overload state
- Admitted 3 times in the last 5 months for pleural effusion and ascites.
- His last discharge was on 16/6/22, for which he was admitted
secondary to fluid overload.

Medication History:
- Aspirin 100mg PO OD
- Frusemide 120mg PO BD
- Spironolactone 50mg PO BD

Nil Allergies
Family History:
- Unremarkable

Social History:
(+) smoking (-) kava (+) Alcohol

O/E:
Comfortable in nil distress, Oriented to time/ place/ person. GCS
15/15
Vitals:
BP: 112/78 P: 108 SPO2: 97%

Chest:
Cachexic looking
Elevated JVP
mild tracheal deviation to the left
dullness to percussion on the right
Air expiration decreased bilaterally
Bilateral basal crepitations (R>L)
Normal S1S2
Abdomen:
Grossly distended
Bulging flanks when patient lying supine
(+) fluid thrill
(+) shifting dullness

Extremities:
Bilateral Grade 3 (+++) pitting edema up to thigh
No peripheral cyanosis
Good volume pulse
Genetilia:
(+) bilateral scrotal swelling
(+) transillumiantion positive
(-) tender
(-) erythema
(+) fluctuation
Assessment:
1) Fluid over load state
2) Hydrocele secondary to fluid overload state
3) Congestive Cardiac Failure
4) Hypertension
Plans:
1) Admit
2) Bloods: FBC/ UECr/ Lipids
3) Meds: Frusemide 40mg IV BD
Aspirin 100mg PO OD
Spironolactone 50mg PO BD
4) Chest Xray
5) ECG
6) Monitor Urine Output
7) Scrotal scan if pain of genetilia
8) IDC
9) Pleural tap to be performed
10) Dietitian to see
Labs:
WBC: 6900
HGB: 13.7
RBC: 4.7 x 10^6
HCT: 39%
MCV: 90fL
MCH: 28pg
PLT: 200K
Chest X-ray