75 year old male with swelling and pain over epigastric region

15/06/23

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CHIEF COMPLAINTS

A 75 year old male, farmer came to OPD with chief complaints of swelling over the abdomen since 5 years and pain over the swelling since 15 days.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 5 years ago and then he noticed a swelling over his epigastric region, insidious in onset, size of a peanut which gradually progressed to the present size like lemon . It was slightly reducible to lying down. No aggravating and relieving factors. Patient also complained of pain over the swelling since 15 days, which was sudden in onset, non progressive, stabbing type of pain, no radiation of pain. No aggravating or relieving factors. Patient had increased work load before 15 days for almost a month.

No history of trauma, chronic cough, shortness of breath, constipation, loose stools, vomiting, fever, cold, burning micturition. No history of chest pain, palpitations, weight loss.

PAST HISTORY:

No similar complaints seen in the past.

Not a known case of Diabetes Mellitus, Hypertension, Tuberculosis, Epilepsy, Thyroid disorders, CAD etc.

No blood trnasfusion

Surgeries: Patient has a history of ESWL for left renal calculi.

Drugs: Uses painkillers for his knee pains every once or twice a week for two days. He got checked for his knee pains, it turned out to be just wear and tear of cartilage due to his old age. Not on any other medications.

FAMILY HISTORY:

No significant history

PERSONAL HISTORY:

Married

Diet is mixed

Appetite is normal

 Sleep is adequate

 Normal Bowel and Bladder movements

No known allergies. 

Patient was a chronic smoker (chutta) from the age of 11, takes toddy (1 bottle). He reduced his intake from 3 years and takes it occasionally now. Last consumption was 1 month ago.

GENERAL EXAMINATION:

Patient was conscious, coherent and cooperative.  Moderately built and nourished.

no pallor, icterus, cyanosis, clubbing, lymphadenopathy, 

Bilateral pitting type of pedal edema

Vitals: 

BP: 120/80mmHg

 PR: 82bpm 

 Temp: afebrile

 RR:17cpm

SYSTEMIC EXAMINATION:

Per abdomen:  

Inspection 

Shape of the abdomen is round, flanks are free, Umbilicus is centrally placed, inverted.

 A solitary swelling noticed in the epigastric gastric region of the size 4*3cm, oval in shape, smooth, well defined margins, skin over the swelling and around the swelling is normal,moving with respiration.

 Scars of vaccination, done in his village, present on either sides of the umbilicus. 

sinuses, visible pulsations, dilated veins seen. No pigmentation. 

Palpation

all inspectory findings confirmed except the size being 5*3cm. 

No local rise of temperature.

 Tenderness present only at the site of swelling that is in the epigastric region. 

Cough Impulse is not present.

 Liver and spleen not palpable.

 Kidney not palpable.

Percussion

dull note present over the swelling, tympanic note heard in other areas. 

No fluid thrill or shifting dullness. 

Auscultation 

Bowel sounds heard 

CVS: S1,S2 heard, No murmurs, thrills

Resp: BAE + NVBS +

CNS: No neurological focal deficits are seen.

PROVISIONAL DIAGNOSIS:

Epigastric Hernia...?

 INVESTIGATIONS:

Random blood sugar: 170mg/dl

Total bilirubin: 0.97 mg/dl

Direct bilirubin: 0.2 mg/dl

SGOT: 10 IU/L

SGPT: 10 IU/L

PROVISIONAL DIAGNOSIS:

Chronic ITP…?

TREATMENT:

1. IV fluids- NS @ 50ml/hr

2. Monitor vitals 4th hourly

3. Input/Output charting