Epigastric lump.ppt

Epigastric lump

1. A Case
of
Epigastric Lump

2. Particulars of the patient
•Name:Md. ErshadAli
•Age:52yrs
•Sex:Male
•Religion:Islam
•Marital status: Married
•Occupation:Service
•Present address: House# 967; Road# 15; Adabor, Dhaka.
•Permanent address: Village: Parkulihar; PO: Napitpara; Upazilla: Manda; District:
Naogaon
•Date and time of admission: 10:00am on 14.03.2016
•Date and time of examination:09:00am on 15.03.2016

3. Chief complaints
1.Recurrent swelling on the lower part of chest for 16 years
2.Pain and itching over the swelling for 9 months

4. History of present illness
Thepatient’spresentingillnessstartedabout16yearsbackwhenhe
noticedappearanceofasmallpainlesslumpovertheepigastricregion,
whichwasgraduallyincreasinginsize.After14yearsofuneventful
progression,itwassurgicallyremovedin2014followedbyrecurrenceafter
fewweeks.Itwasre-operatedin2015.Andagainrecurrenceoccurred.
Unfortunately,inneitherofthecircumstances,thetissuewassentfor
histopathologicalexamination.

5. History of present illness(contd.)
Thepatientstartedtofeelcontinousdull-achingpainwithinthelump9
monthsago,whichispersisting.Thepainwasinsisiousinorigin,localized,
mildinintensitywithnosignificantaggravatingfactorsbutrelievedby
variousanalgesicswhichhecouldnotelaborate.Healsocomplainsofmild
intermittentitchingoverthelump.
Thereisnohistoryofhematemesisandmelaena,difficultyinbreathing,
fever,cough,hemoptysis,chestpain,bonepainorjaundice.Hisboweland
bladderhabitsarenormal.

6. History of past illness
The patient gives no significant history of past illness.
Drug history
Tab. Olmesartan 20mg for 1 year.
Medical history
He has no history of diabetes mellitus, tuberculosis, asthma or COPD. He
has primary hypertension for which he has been taking Tab.
Olmesartan for 1 year.

7. History of allergy
He has no history of allergy to any known drug or food.
History of immunization
Patient is immunized, but he could not elaborate.
Personal history
He is a smoker, taking approx. 5-10 sticks/day for the last 37 years. He is
non-alcoholic.

8. Family history
His family consists of his wife and two sons. None of his family members
and relatives is suffering from such type of illness.
Socioeconomic history
He comes from a average income background. He lives in a building. He
drinks clean water and uses sanitary latrine. He takes average Bangladeshi
meals everyday.

9. General Examination
•Cooperation:Cooperative
•Appearance:Normal
•Body-build:Average
BMI?
•Decubitus:On choice
•Nutrition: Average
•Intelligence:Normal
•Anemia: Absent
•Jaundice: Absent
•Cyanosis:Absent
•Cyanosis:Absent
•Clubbing:Absent
•Koilonychia: Absent
•Leuconychia: Absent
•Edema:Absent
•Dehydration:Absent
•Pigmentation: Absent
•Hair distribution: Normal
•Deformities:Absent
•Lymph nodes: Not enlarged
•Thyroid gland: Not enlarged
•Neck veins:Not engorged
•Pulse:66 beats/min
•Blood pressure: 150/100 mmHg
•Temperature:98
o
F
•Respiratory rate: 16 breaths/min

10. Systemic Examination
Abdomen:
•Inspection:
Shapeofabdomen:Normal(scaphoid)
Flanks:Notfull
Umbilicus:Centrallyplaced,inverted,verticallyslit
Skincondition:3cmlongtransversescarmarkpresentonthe
upperpartoftheepigastricregion
Hairdistribution:Normal
Visibleperistalsis:Absent

11. Systemic Examination(contd.)
Inspection:(contd.)
Visiblepulsation:Absent
Visibleengorgedveins:Absent
Groins:Normal
•Palpation:Superficial
Temperature:Normal
Tenderness:Presentontheareaoverlyingthelumponthe
epigastricregion
Muscleguard:Absent

12. Systemic Examination(contd.)
Palpation: Superficial (contd.)
There is a lump on the epigastric region,
Position : epigastricregion
Colour: some discoloration present
Temperature : not raised
Tenderness : present
Shape : irregular
Size : Measuring about 4cm ×6cm
Surface :irregular
Edge : irregular

13. Systemic Examination(contd.)
Palpation: Superficial (contd.)
Composition
Consistency : Hard
Fluctuation : Absent
Fluid thrill : Absent
Translucency : Absent
Resonance : Absent
Pulsatility: Absent
Compressibility : Absent
Bruit : Absent

14. Systemic Examination(contd.)
Palpation: Superficial (contd.)
Reducibility : Not reducible
Relations to surrounding structures : Fixed to skin, free from
underlying structure.
Regional lymph nodes : Not involved
State of local tisuues:
Arteries
Nerves
Bones and joints

15. Systemic Examination(contd.)
•Palpation: Deep
Liver, gall bladder and spleen: Not enlarged
Kidneys: Not palpable or ballotable
No other palpable lump in the abdomen
•Percussion:
Percussion note: Tympanic all over the abdomen, except dull over
the lump
Upper border of liver dullness: In the 5
th
intercostal space on
right midclavicular line
Shifting dullness and fluid thrill: Absent

16. Systemic Examination(contd.)
•Auscultation:
Bowel sound: Present
Vascular bruit: Absent
•Digital rectal examination: NAD
Cardiovascular system: NAD
Genitourinary system: NAD
Nervous system: NAD
Musculoskeletal system: NAD
Integumentarysystem: NAD. No café-au-laitspots present.

17. Salient Features

19. Provisional Diagnosis?

20. Soft Tissue Sarcoma

21. Differential Diagnosis
•Keloid
•Hypertrophic scar
•Calcified lipoma

22. Investigations
•CBC with ESR: Hb% -14.2%
ESR -20mm in 1
st
hour
WBC –6700/mm
3
Neutrophil -53%
Lymphocyte -37%
Monocyte -6%
Eosinophil -4%
Basophil -0%
•Ultrasonogram of Whole Abdomen: