A 75 year old male patient with pain in epigastric region since 10 days and gradually increasing swelling since 5 years - CASE 16

9th June 2023
CASE STUDY 16

Hello, I am Saloni .S. Gangotri , a 5th semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.

CASE SHEET:

CHIEF COMPLAINTS:
c/o 
- pain in epigastric region since past 10 days.
- increasing swelling in the epigastric region which initially began 5 years ago.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 5 years ago until until he noticed a peanut sized swelling in the epigastric region which was initially not associated with pain. The size of the swelling gradually increased through the years, with no pain but bloating felt. 10 days back there occurred pain in the area of the swelling which was sudden in onset, gradually progressive, non radiating and presented right after eating food. The pain was not relieved on passing stools but was relieved on medication. 

3 years ago he was diagnosed with renal calculi which was treated with blast surgery.
He also has arthritis in both the legs since 6 years for which he was prescribed medication but stopped consuming them 20 days back.

-no h/o burning micturition and reduced urine output
-no h/o itching
-no h/o of vomiting 
-no h/o diarrhea 
-no h/o fever 
-no h/o nausea 
-no h/o rash
-no h/o constipation 
-no h/o cough
-no h/o headache, blurring of vision.



ASSOCIATED DISEASES:

———

PAST HISTORY:

No K/C/O HTN, DM, Epilepsy, TB, CAD, CKD. 
h/o of Blast surgery 3 years ago to cure renal calculi.

PERSONAL HISTORY:

Married.
Labourer by occupation.
On a mixed diet.
Adequate sleep.
Normal appetite.
Normal Bowel movements. 
Has no known allergies.
Was occasional alcoholic and regular smoker (gutka) but stopped smoking 5 years ago.


FAMILY HISTORY:


Has N/K/C/O  Diabetes Mellitus, No HTN, No Strokes. No CAD, TB, Asthma or Epilepsy.


DRUG HISTORY:








GENERAL EXAMINATION:

-No palor
-No Icterus
-No cyanosis 
-No lymphadenopathy
-No pedal edema 
-No clubbing of fingers














VITALS:

Temperature: Febrile - 98.9°F

Pulse: 76 beats per minute

Respiratory rate: —16 cycles per minute

Blood pressure: 110/70 mm of Hg

SPO²: 100%

GRBS: 129mg%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills
No murumurs
Cardiac sounds: S1, S2 present 

Respiratory system:

Barrel shaped chest
No dyspnea
No wheezing
Breath sounds heard: vesicular? yes

Abdomen:

Shape : Scaphoid
Tenderness present on epigastric region 
Palpable mass present in epigastric region - 5x5 cm
non palpable spleen
Non palpable liver
No free fluid (ascites) present 
No bruits
Bowel sounds: heard




Central Nervous System:

Conscious and Alert 
Speech: Normal

INVESTIGATIONS:
Biochemical investigations:
ECG:


2D-ECHO REPORT:

---


ULTRASOUND REPORT:


GRAPHIC SHEET :


---



PROVISIONAL DIAGNOSIS:
———






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