FINAL SHORT l
This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through a series of inputs from an available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient-related online learning portfolio and your valuable inputs on the comment box.
Consent and de-identification: The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being conserved entirely. No identifiers shall be revealed throughout this piece of work.
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 back, 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
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