2. Particulars of the patient
• Name: Md. Ershad Ali
• 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
The patient’s presenting illness started about 16 years back when he
noticed appearance of a small painless lump over the epigastric region,
which was gradually increasing in size. After 14 years of uneventful
progression, it was surgically removed in 2014 followed by recurrence after
few weeks. It was re-operated in 2015. And again recurrence occurred.
Unfortunately, in neither of the circumstances, the tissue was sent for
histopathological examination.
5. History of present illness (contd.)
The patient started to feel continous dull-aching pain within the lump 9
months ago, which is persisting. The pain was insisious in origin, localized,
mild in intensity with no significant aggravating factors but relieved by
various analgesics which he could not elaborate. He also complains of mild
intermittent itching over the lump.
There is no history of hematemesis and melaena, difficulty in breathing,
fever, cough, hemoptysis, chest pain, bone pain or jaundice. His bowel and
bladder habits are normal.
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: 98o F
• Respiratory rate: 16 breaths/min
10. Systemic Examination
Abdomen:
• Inspection:
Shape of abdomen: Normal (scaphoid)
Flanks: Not full
Umbilicus: Centrally placed, inverted, vertically slit
Skin condition: 3 cm long transverse scar mark present on the
upper part of the epigastric region
Hair distribution: Normal
Visible peristalsis: Absent
11. Systemic Examination (contd.)
Inspection: (contd.)
Visible pulsation: Absent
Visible engorged veins: Absent
Groins: Normal
• Palpation: Superficial
Temperature: Normal
Tenderness: Present on the area overlying the lump on the
epigastric region
Muscle guard: Absent
12. Systemic Examination (contd.)
Palpation: Superficial (contd.)
There is a lump on the epigastric region,
Position : epigastric region
Colour : some discoloration present
Temperature : not raised
Tenderness : present
Shape : irregular
Size : Measuring about 4cm × 6cm
Surface : irregular
Edge : irregular
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 5th 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
Integumentary system: NAD. No café-au-lait spots present.
