75 year with epigastric herina
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I have been assigned this case to develop my competency in reading and comprehending clinical data, including the patient's history, clinical findings, and investigations, in order to come up with a diagnosis and treatment plan.
Case Summary:
Patient Information:
- 75-year-old male resident of Narsapuram, working as a laborer.
Chief Complaints:
- Swelling over the abdomen for the past 6 years.
- Pain over the swelling for the last 10 days.
History of Presenting Illness:
The patient was initially asymptomatic for 6 years until he noticed a sudden-onset, gradually progressive swelling in the epigastric region. The size of the swelling started as 1x1 cm (peanut-sized) and has now progressed to 5x5 cm, assuming a spherical shape. The swelling is firm in consistency, non-mobile, and shows no transillumination or fluctuation. It is aggravated by food consumption and relieved by rest. The patient experiences stabbing pain localized to the swelling, with no associated secondary changes.
There is no history of fever, burning micturition, pain while passing urine, decreased urine output, chest pain, palpitations, paroxysmal nocturnal dyspnea (PND), orthopnea, shortness of breath (SOB), cough, cold, wheezing, abdominal pain, distention, vomiting, diarrhea, constipation, fever, nausea, vomiting, or headache.
Past History:
- No similar complaints in the past.
- No known case of chronic obstructive pulmonary disease (COPD), tuberculosis (TB), asthma, hypertension (HTN), coronary artery disease (CAD), cerebrovascular accident (CVA), epilepsy, or thyroid disease.
- Three years ago, the patient had kidney stones and received shockwave lithotripsy for treatment.
Family History:
- Not significant.
Personal History:
- Mixed diet, normal appetite, adequate sleep, and no changes in bowel and bladder movements.
- No known allergies.
- History of tobacco smoking since the age of 11. Used to cultivate tobacco on a farm, made it into "bedi" for smoking. Later, started chewing tobacco.
- Previously consumed 1 to 2 packs of cigarettes per day, resulting in a smoking index of 2 x 60 years = 120 pack-years.
- Used to consume toddy (1 liter per day) and later alcohol occasionally (60 ml). Quit drinking and smoking 5 years ago due to family reasons.
General Examination:
- The patient is conscious, coherent, cooperative, well-built, and nourished.
- Examination performed in a well-lighted room, with the patient exposed from the neck to the pubis.
- Pallor is present, while icterus, cyanosis, clubbing, generalized lymphadenopathy, and bilateral pedal edema are absent.
Vital Signs:
- Blood pressure: 120/80 mmHg
- Pulse rate: 85 bpm
- Respiratory rate: 18 cpm
- Oxygen saturation (SpO2): 99% on room air
Systemic examination:-
Per abdomen:
Inspection:
Round, large with no distention
Umbilicus: Inverted and central
Solitary swelling seen in xiphisternum 5*5 cm spherical shape with clear borders and surroundings appears to be normal and smooth surface .
No visible pulsation,peristalsis, dilated veins .
Palpation:
No local rise of temparature ,tenderness present in epigastric region
Edge: Well-defined, indistinct
• Consistency: firm
• Reducibility: reducible
Percussion:
No fluid thrill, shifting dullness absent
Auscultation:
Bowel sounds heard 10/minute
CVS:
Inspection:
There are no chest wall abnormalities
The position of the trachea is central.
Apical impulse is not observed.
There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses.
Palpation:
No local rise of temparature and no tendersness
Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line
Position of trachea was central
Auscultation:
S1 and S2 were heard
There were no added sounds / murmurs.
RESPIRATORY SYSTEM:
Inspection: chest shape : bilaterally symmetrical elliptical
Movement : bilaterally symmetrical
No scars , sinuses , engorged veins
Trachea appears to be central
Palpation: No rise in temperature and no tenderness , Apex beat felt at 5 intercostal spaces.
Expansion of chest is bilateral symmetrical in anterior, apical and posterior areas.
Trachea location central .
Tactile vocal fremetus : resonant in all areas
Percussion: All areas appears are resonant.
Auscultation:BAE present, No added sounds
CNS :
HIGHER MENTAL FUNCTIONS- Normal
Memory intact
CRANIAL NERVES :Normal
SENSORY EXAMINATION
Normal sensations felt in all dermatomes
MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
CEREBELLAR FUNCTION
Normal function
No meningeal signs were elicited
Provisional diagnosis:
Epigastric hernia with accidental thrombocytopenia
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