Case presentation abdominal swelling.pptx

Case presentation abdominal swelling.pptx

1. Female with abdominal wall swelling. Muhammad Asad MC/2025/062

2. CONTENT: Clinical history Examination Differential diagnosis Investigation Management plan Pathological correlation Background Information

3. Biodata: PATIENT NAME : Parveen AGE: 60 years GENDER: female OCCUPATION: housewife MARITAL STATUS: Married having 6 children RESIDENT of: orangi town WITH NO KNOWN COMORBIDS

4. Presenting Complaint: She presented in LNH ER on 28th of march with the complain of: Abdominal swelling for 2 years Pain in swelling for 17 days Vomiting for 17 days

5. HOPC According to the patient she was in usual state of health, 17 days back when she develop pain in her abdominal wall swelling which she had for 2 years Swelling was sudden in onset gradually increasing in size, initially the size of a marble, Currently size of tennis ball. The swelling was single and there was not any other swelling in the body. Pain was gradual in onset, colicky in character, continuous and progressive in nature, rated 8/10 on scale of severity , relieved on taking painkillers, no aggravating factors, not associated with fever and chills. She also complains of 8 to 9 episodes of vomiting in the last 17 days . Vomiting was projectile in nature, quantity of one cup, containing food particles in it yellow in color and having no foul smell with no relieving or aggravating factors and she has no history of hematemesis. With these complains, she visited a peripheral hospital at first where she was given iv drip for pain and vomiting One day later she started experiencing same symptoms and visited LNH ER on 28 march 2:30 AM

6. Past medical and surgical : insignificant Systematic review: CNS :There is no complain of headache, blurry vision, blackouts , dizziness. Respiratory System : There is no complain of shortness of breath , cough, sputum, or wheezing CVS: There is no complain of palpitation, chest pain, dyspnea, orthopnea or Paroxysmal nocturnal dyspnea was reported GIT : she did complain of, vomiting, abdominal pain , but no complain of diarrhea or constipation ,hematemesis, melena, jaundice. Genitourinary Tract : she has an indwelling catheter. Endocrine System : There is no complain of heat or cold intolerance, polyuria, nocturia, polyphagia, weight gain or loss. Musculoskeletal System : There is no complain of joint stiffness , bone pain, muscle ache, restriction of movement.

7. Personal history: patient reported that her appetite and sleep was disturbed because pain, no history addiction or weight gain or loss. She has no history of blood transfusion. No allergies Drug history: no drug history Menstrual history: she is postmenopausal for 10 years Obs history: 6 children all delivered via Normal spontaneous vaginal delivery. Family history: insignificant Socioeconomic: satisfactory

8. General physical examination My patient was ill looking lying uncomfortably on the bed, well oriented to time place and person, She had a foleys catheter with 50 ml urine output, and iv cannula was inserted on the right hand. Vitals BP: 139/84 Heart rate: 88 RR : 18 bpm Temperature: Afebrile

9. Hands: On examining the hands,there was no visible deformity, size and shape of the hands were normal .Palmar sweating and erythema was absent . Pallor was visible but there was no cyanosis. Nails : No clubbing, splinter hemorrhages, koilonychia, pitting of nails were present. Arm s: There was no evidence of bruising, excoriation, or scar marks Fingers: No osler nodes , bouchard's nodes were palpable. Interphalangeal joints were normal. There was no visible deformity Face: Facial appearance was normal. No periorbital edema, no proptosis, no xanthelasma or skin rash was present . Color of lower conjunctiva was red. No signs of anemia and jaundice have been appreciated. Parotid glands were not enlarged. There was no angular cheilitis. No teeth deformity. No blisters were present on either tongue or buccal mucosa. Neck: On examining the neck , no swelling was present, no previous surgery scar marks were present. Deglutition and tongue protruding test were normal. No cervical, occipital or supraclavicular lymph nodes were palpable. Neck veins were not engorged. No visible venous pulsations were present. Axilla : Axillary lymph nodes were not palpable . Groin: Groin lymph nodes were not palpable.

10. Abdominal examination: Inspection: On inspection, the abdomen was generally distended. Abdomen was moving symmetrically with respiration. Umbilicus was central and of crescent shape . There was visible mass on paraumbilical region more towards the right sided , single in number, non lobulated, size of a Tennis ball. No overlying skin discoloration or ulcerative lesion was noted. No visible venous or aortic pulsations were present. Cough impulse was Positive but, no stria, prominent veins or caput medusae was present. Palpation: on palpation the swelling was not tender, and non reducible. Transillumination was negative Superficial Palpation of abdomen: was soft in consistency ,no rigidity or tenderness was present Deep Palpation: On palpating visceras, lower border of the liver was not palpable, spleen and kidneys were also not palpable suggesting that no visceromegaly was present.

11. Percussion: On percussion, normal tympanic note was present,. Shifting dullness and fluid thrill was negative. Auscultation: On auscultation, less than 1 bowel sound per minute was present. No bruit was audible. DRE: the consent of DRE not given. OTHER SYSTEMIC EXAMINATION: Respiratory Examination: On inspection, shape of the chest was normal. No deformity, scars, prominent veins or pulsations visible. Chest was moving equally on both sides . On palpation, trachea was central ,no tenderness or crepitus was present. Percussion reveals normal resonance on both the sides. On auscultation, normal vesicular breathing with no added sound was present. Vocal resonance was also normal. Cardiovascular Examination: On inspection, there were no scar marks, pulsations or pigmentations were present. On palpation, apex beat was palpable at 5th intercostal space in mid clavicular line .

12. Note the crescent shaped umbilicus

13. Differential diagnosis Paraumbilical hernia Incisional hernia Abdominal cysts Lipoma Sebaceous cyst

14. Investigations CBC UCE CRP Serum electrolytes PT/INR Lfts ULTRASOUND CT ABDOMEN

15. Management Supportive : IV fluid resuscitation Electrolytes Replacement Broad Spectrum antibiotics Surgical: Open or laparoscopic hernia repair

16. HERNIA A hernia is the bulging of part of the internal body part through a weakness in the muscle or surrounding tissue wall.

17. Causes Weakness due to structure entering and leaving the abdomen Developmental failures Genetic weakness of collagen Sharp and blunt trauma Weakness due to ageing and pregnancy Primary neurological and muscle disease

18. Pathophysiology Defect or weakness in the muscular wall maybe congenital, acquired or traumatic increase in intra abdominal pressure as a result of any risk factor, The abdominal contents can protrude causing herniation.

19. Sign and symptoms Bulge in or near the umbilicu s that usually gets bigger when straining, lifting or coughing Pressure or pain at the hernia site Constipation Sharp abdominal pain with vomiting — this can be a sign of a strangulated hernia and is a medical emergency

20. Investigation For most hernias, no specific investigation is required, the diagnosis being made on clinical examination. Ultrasound scan CT scan is investigation of choice

21. Management Not all hernias require surgical repair. Pain, tenderness and skin colour changes imply high risk of strangulation . Very small defects less than 1 cm in size may be closed with a simple figure-of-eight suture, or repaired by a darn technique where a non-absorbable, monofilament suture is criss-crossed across the defect. Defects up to 2 cm in diameter may be sutured primarily with minimal tension, although, the larger the defect, the more tension and the more likely it is that mesh reinforcement will be beneficial. For defects larger than 2 cm in diameter, mesh repair is recommended. (Open or laparoscopic umbilical hernia repair)

22. Surgical management Surgical manage includes Reducing hernial content into the abdominal cavity by removing non-viable tissue and repairing the bowel Permanent reinforcement of the abdominal wall defect with sutures or mesh. Reduction of hernial content is essential for a successful repair. “M esh” refers to prosthetic material, either a net or a flat, sheet, which is used to strengthen a hernia repair. Mesh can be used: to bridge a defect - the mesh is simply fixed over the defect as a tension-free patch to plug a defect - a plug of mesh is pushed into the defect to augment a repair - the defect is closed with sutures and the mesh added for reinforcement.

23. Hernia mesh, also known as surgical mesh, is a medical device used to support protruding tissue around a hernia The mesh may be placed in one of several anatomical planes: Within the peritoneal cavity In the retromuscular space In the extraperitoneal space In the subcutaneous plane