A 75 Y/O MALE WITH EPIGASTRIC SWELLING
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Chief complaints:
A 75 y/o male, labourer by occupation, presented with chief complaints of:
→ swelling over the abdomen since 6 years
→ pain over the swelling since 7 days
History of presenting illness:
The patient was apparently asymptomatic 6 years ago, then
→ he noticed a swelling above his stomach (epigastric region), which was peanut-sized and gradually progressed to the present size. The swelling was firm in consistency, non-mobile, and shows no signs of transillumination or fluctuation. It is aggravated on consuming food and relieved by rest.
→ he developed pain over the swelling which was insidious in onset, stabbing type in nature, non radiating, aggravated on work and relieved on rest.
No h/o fever, nausea, vomiting, chest pain, palpitations, shortness of breath, cough, wheeze, abdominal pain, distension, constipation, or varicose veins.
Past history:
No similar complaints in the past
Not a known case of chronic obstructive pulmonary disease, tuberculosis, asthma, hypertension, coronary artery disease, epilepsy, or thyroid disease.
Three years ago, the patient had left sided renal calculi and received shockwave lithotripsy as treatment.
h/o knee pain, on and off for 6 months, for which he used an unknown NSAID.
Personal history:
Diet: mixed
Appetite: decreased
Bowel and bladder movements: regular
Sleep: adequate
Addictions:
→ smoking since the age of 11(1 - 2 packs per day)
→ chewing tobacco
→ toddy consumption (500 ml - 1000 ml per day)
→ alcohol consumption (60 ml per day)
Quit all addictions 5 years ago.
General examination:
The patient is conscious, coherent and cooperative, moderately built and nourished, and is well oriented to time, place and person.
Pallor: absent
Icterus: absent
Cyanosis: absent
Clubbing: absent
Koilonychia: absent
Pedal edema: absent
Lymphadenopathy: absent
Vitals:
Temperature: afebrile
Respiratory rate: 19/min
Blood pressure: 120/80 mm Hg
Pulse: 83 bpm
Systemic examination:
Per abdomen:
Inspection:
Shape: round, large, no distension
Umbilicus: inverted
Solitary swelling seen in epigastrium, spherical in shape, of 5 cm radius, having clear borders.
Skin surrounding the swelling appears normal and smooth.
No scars, swellings, dilated veins, visible pulsations
Palpation:
No local rise of temperature
Tenderness present
Edges of swelling: well-defined
Consistency: firm
Reducibility: reducible
Percussion:
No shifting dullness
No fluid thrill
Auscultation:
Bowel sounds heard
Cardiovascular system:
S1, S2 heard
No murmurs
Respiratory system:
BAE +⃝
Trachea: central
Vesicular breath sounds heard
Central nervous system:
Patient is conscious
No focal neurological deficits
Provisional diagnosis:
Epigastric hernia
Investigations:
Random blood sugar: 170 mg/dL
Serum Na: 143 mEq/L
Serum K: 4.5 mEq/L
Serum urea: 57 mg/dL
Serum creatinine: 2.2 mg/dL
Total bilirubin: 0.97 mg/dL
Direct bilirubin: 0.2 mg/dL
SGOT: 10 IU/L
SGPT: 10 IU/L
Treatment:
NS at 50ml/hour
Monitor vitals every 4 hours
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