Patients case

presentation

Dr. Mohammed Sanwar Hussain

Intern Doctor Medicine Unit II
Sylhet MAG Osmani Medical college and Hospital
• A 50 years male admitted with mass in the
abdomen for 1 month
 Particulars of the patient

• Name : Mr. Bimol Sutrodhar

• Age : 50 years(Male)
• Father’s Name : Late Bihari Sutrodhar
• Occupation : polli chkitshak
• Religion : Hindu
• Address : Hobibpur, shallah, Sunamganj
• Date of Admission : 06.05.19 at 3.20pm
• Date of examination : 10.05.19 at 3.00pm
 Chief Complaints:
• Mass in Abdomen for 1 months
• Anorexia, weight loss & Abdominal fullness for the same duration
 History of present illness

• According to the statement of the patient, he was reasonably well 8 months

back. Since then he has been suffering raised temperature on abdomen
measuring around 100 degree Farenheit. Fever use to come at afternoon and
go at night. Associated with shivering. It occasionally reduced after taking
Azithromycin. There is no history of induced or projectile vomitting. The
patient also complains of weakness, marked loss of appetite and weight loss
for the last 3 months. There is no history of melena or cough. His bowel
habits altered
 History of past illness
• He has history of knee joint swelling and walking difficulty since 2004
• Haemorrhoids Grade I
 Family History
• 7 brothers & 3 sisters
• One brother Had abdominal TB and died 2 years after following disease
almost 15 years back.
 Personal history
• He is a polli chikitshak and used to smoke.
 Socioeconomic history
• He is from lower socioeconomic condition and lives in rural area
 Drug history
• Azithromycin
• Algin
• Ketorolac
• Monas
 General examination

• Ill looking • No lymphadenopathy

• Mildly anemic • Pulse:66 bpm
• No jaundice,cyanosis,clubbing, • BP: 110/70 mmHg
• No koilonychias,leukonychia • Temperature:101 degree
• Ascites present • Respiration: 18 breaths/min
 Systemic Examination
Gastrointestinal system:
Lips are tar stained, teeth is black stained. Upper margin of incisor teeth lost.
Tongue is dry and whitish(oral thrush)
 Abdomen
• Inspection: visible mass in above umbilical region. Abdomen slightly distended
• Auscultation:Boborygmi Audible
• Percussion: Tympanic,dullness over mass region
• Palpation:There is ill defined mass in the umbilical region, 1 x 1 cm, margin
irregular,tender,firm in consistency,surface slightly irregular,fixed from side to side
• Liver:not palpable
• Spleen:not palpable
• Kidneys:not ballotable
• Examination of other systems reveals no other Abnormalities
 Differential Diagnosis

• Carcinoma of stomach
• Abdominal TB
 Investigations
• CBC with ESR
• RBS
• Serum electrolyte
• Serum creatinine
• USG of Whole Abdomen
 Plan
• Endoscopy of upper GIT
• CT scan of abdomen