SURGERY CLINICAL CASE

PRESENTATION
SHIVA ROOBINI R
FINAL YEAR MBBS STUDENT
COIMBATORE MEDICAL COLLEGE
.

Mr X ,A 56 year old male security guard from annur came to op

with chief complaints of ,

- pain in the right lower abdomen for the past 1 month

- swelling over the right lower abdomen for past 1 month

HISTORY OF PRESENTING COMPLAINTS
The patient is apparently normal 1 month back then he experienced
• Lower abdomen pain – right sided
• insidious onset
• continuous dull aching type
• Not associated with food intake
• No aggravating factors ; Relieved only on medication
• Not radiating to any other sites
Then he noticed a hard swelling over right lower abdomen – 1 month
• Insidious onset
• Initially smaller in size , now progressed to the present size
.

• h/o altered bowel habits – 1 week

• Alternate episodes of loose stools and difficulty passing stools
• h/o diarrhoea - 10 episodes per day ,
• h/o Passage of black tarry stools , occasionally frank blooded
• Associated with burning sensation
• no h/o passage of pus or mucus or worms in stool
.

• h/o easy fatiguability and tiredness – 1 week

• h/o loss of appetite and loss of weight
• No h/o abdominal distention
• No h/o nausea and vomiting
• No h/o jaundice and itching
.

• No h/o burning micturition , hematuria

• No h/o cough with expectoration , difficulty breathing
• No h/o swellings in any other regions
• No h/o difficulty in moving knee joint
• No h/o trauma
Past history
• No h/o similar illness in the past
• No h/o previous surgeries
• No h/o previous blood transfusions
• No h/o chronic drug intake
• Not a known case of tuberculosis ,diabetes mellitus , hypertension ,
asthma , coronary heart disease
TREATMENT HISTORY
• Initially after 3 days of complaints the patient went to a private clinic
where oral tablets and injection given to relieve pain
• As his complaints didn’t improve he went to nearby PHC where he
was referred to our institution
Personal history
• Consumes mixed diet
• Altered sleep patterns due to pain
• Consumes alcohol for the past 30 years - brandy 180ml/day thrice a
week
• Smokes 4 cigarettes per day for the past 35 years
• He has stopped smoking and alcohol for the past 1 month
FAMILY HISTORY
• No h/o similar illness in the family
• No h/o any cancer in the family
• No h/o tuberculosis in the family
CONTACT HISTORY
• No h/o contact with active case of tuberculosis
After obtaining informed consent from the patient the patient was
examined

GENERAL EXAMINATION
• The patient is conscious oriented to time, place and person
• MODERATELY BUILT and nourished
• Afebrile
• PALLOR
• Not icteric
.

• No generalised lymphadenopathy
• No signs of dehydration
• Oral cavity – lips and oral mucosa - normal ; nicotine stains present
• Jaw – no swellings
• Skin – no hyperpigmentation
Vitals
• Temperature 96.8 F
• Pulse rate – 78 / min in right radial artery , normal rate ,normal
rhythm, normal volume , character ,no radio-radial or radio-femoral
delay , equally felt in all peripheral sites
• Heart rate – 76 beats /min
.

• Respiratory rate – 14 / min , thoracoabdominal type

• Blood pressure – 120/90 mmHg measured in sitting position in right
arm
• Weight 55 kgs
• Height 173 cms
• BMI 18.4
LOCAL EXAMINATION
After obtaining consent from patient , the patient was made to lie
supine comfortably and exposed from nipple till midthigh and was
examined under adequate light
On INSPECTION
• abdomen was distented over right iliac region
• Umbilicus – midline and inverted
• All quadrants moves equally with respiration
• Fullness noted in right iliac fossa
• An Irregular medium sized mass approximately 7x6 cm
Inspection cont

• Skin over swelling normal

• No scars , sinuses or dilated veins seen
• No visible peristalsis seen
• No movement with respiration
 .
• Cough impulse absent
• Renal angle free
• Hernial orifices free
• External genitalia normal
• No fullness in left supraclavicular region
.
PALPATION
• Patient is instructed to flex the knee and made to lie down
comfortably and the Inspectory findings are confirmed
• No warmth and no tenderness
• No guarding
• No ridigity
.

• An irregular mass of size 8 x 6 cm over right iliac fossa was palpable

extending 5 cm from ASIS
7 cm from umbilicus
12 cm from right costal margin
4 cm above pubic tubercle
• Surface – smooth , hard in consistency all over the mass
.

• Margin – distinct
• Lower border is palpable
• Didn’t move with respiration
• Mobile in all directions
• Non ballotable
.

• Carnett test – mass became less prominent indicating intra-

abdominal mass
• Non pulsatile
• No organomegaly
• Inguinal lymph nodes non palpable
• No other palpable masses in any other quadrants
• Left supraclavicular region – normal
,

• Renal angle – free

• Hernial orifices - free
• External genitalia – normal
• Testis palpable on both sides within the scrotum
On PERCUSSION
• Impaired resonance felt over the mass
• other quadrants - resonant
• No free fluid
• No organomegaly
AUSCULTATION
• Normal bowel sounds heard
• No bruit heard

• PER RECTAL EXAMINATION – not done

OTHER SYSTEMS
• CVS – S1 S2 heard , no murmurs
• RS – Normal vesicular breath sounds heard .no added sounds
• CNS – no focal neurological deficits
SUMMARY
A 56 years old male who is a chronic smoker and alcoholic with no
comorbidities with no positive family history came with
complaints of right lower abdominal pain and mass with history of
malena ,altered bowel habits and on examination appeared pale ,
showed fullness in right iliac fossa with a nontender hard irregular
mass of 8 x 6 cm with palpable lower border and showed
impaired resonance on percussion with no signs of complications.
PROBABLE DIAGNOSIS
• ANATOMICAL – right iliac fossa growth
intra abdominal mass
probably colon mass – CAECAL growth
• PATHOLOGICAL – MALIGNANT growth
Differential diagnosis
• Ascending colon carcinoma
• Ileo-caecal tuberculosis