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case Summary

Maybe this time i would write case summary in my entry here. haha. Just for fun. realizing that i have clerked so many patient, why don't i share some of them with the people. By the way, information here is so confidential so all the identification information will be changed or removed.

Case 1 A 69 years old male presented to the hospital with the chief complain of localized abdominal pain and distension for 4 days. The pain is localized at the epigastric region, stabbing in nature, non-radiating and aggravated by taking food. It is associated with nausea and vomiting. the vomitus contain partially digested food particles. The distension at the epigastric region was noticed by the patient himself after the epigastric pain occured. On further questioning, patient also loss his appetite and weight since 4 months ago and had an altered bowel habit since 2 months ago. Patient was having difficulty in passing hard and small amount of stool. There were no blood noticed in the stool. On examination, patient is comfortable however looks cachexic. Pallor was noted on conjuctiva however there is no jaundiced noted on sclera. There is mild pedal oedema noted. Abdominal examination reveals a hard, tender and fixed mass measuring around 8cm X 10 cm oval shape mass in the epigastric region. Liver and spleen are not enlarged and kidneys are not ballotable. Mild shifting dullness can be elicited on percussion. The mass is also dull on percussion. Bowel sound is present and no bruit heard on auscultation of abdomen.

Per rectal examination done and no mass is noted.

Other systems reveal no abnormality.

Diagnosis: You think about it! hahaha.


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