SURGERY
LUMP ABDOMEN CASE SHEET
NAME OF THE PATIENT :
SEX :
AGE:
OCCUPATION :
ADDRESS :
CHIEF COMPLAINT:
patient presented with chief complaint of swelling in the mass in the abdomen since__ or pain in the
abdomen since___ or abdominal distention since-----
H/O PRESENT ILLNESS :
duration of the swelling ,
exact size at the time of onset,
exact site at the time of onset,
progression,
sudden increase in size of the swelling or sudden decrease in size of the swelling,
h/o trauma
h/o pain--duration,site,nature,radiating or not,aggreviating and relieving factors,
h/o loss of appetite
h/o loss of weight
h/o nausea , vomiting (duration , frequency per day, projectile or non projectile , contents (gastric or
bilious or food particles, blood stained or not , aggreviating and relieving factors )
h/o indigestion
urine color
stool color(black colored tarry stools—malena which is indicative of upper GI bleeding)
clay colored fowl smelling stools –steatorrohea (obstructive jaundice)
itching
bleeding gums
PAST HISTORY :
similar complaint in the past
h/o TB,
h/o HTN
h/o DIABETIS
h/o asthma ,
h/o previous abdominal surgeries
FAMILY HISTORY : carcinoma of the lung and any cancers
PERSONAL HISTORY :
h/o smoking
h/o alcholism,
bowl and bladder disturbances ,
GENERAL EXAMINATION :
palor, icterus , cyanosis , clubbing , lymphadenopathy ,edema
scratch marks
purpuric patches
bleeding tendencies
VITALS :
temperature ,
pulse rate
blood pressure
respiratory rate
INSPECTION :
examining the patient in supine position with hands placing by the side of patient with legs fully
extended
shape of the abdomen: (scaphoid or normal or distended)
skin over the abomen:
color ,
pigmentation ,
discharge ,
ulcers ,
sinus ,
nodules ,
fistulas ,
dilated veins
umblicus :
position—moves up in pelvic tumors and moves down in ascities
shape (inverted or everted)
peri umblical nodules
peri umblical dilated veins
movements with respiration—peristatilitic movements and pulsatile movements
flanks –(concave inwards or convex outwards)
hernial orifices examination
swelling features:
for swelling - number ,
situation ,
size ,
shape
borders -well defined or not ,
extension ,
skin over the swelling --red or shiny or any other changes ,
surface of the swelling,
any engorged veins,
any visible pulsations,
expansile impulse on cough ,
swelling moves down with respiration
leg raising test : ( if the swelling becomes less prominent on raising both extended legs it is intra
abdominal)
PALPATION : patient is in supine position and legs semi flexed
Tone of the abdomen –rigidity or guarding
Local raise of temperature
tenderness over the swelling ,
all inspectory findings of swelling are confirmed ,
mobility ,
consistency
plane
palpate for spleen
palpate for liver
PERKUSSION :
check for the presence of fluid—
fluid thrill (minimum of 2000ml is required)
shifting dullness (1000ml is required)
puddle ‘s sign (120ml is required)
ultrasound can detect up to 30ml of fluid
liver dullness
spleen dullness
AUSCAULTATION :
bowl sounds
systemic examination : CVS and RESPIRATORY
EXAMINATION OF SCROTUM :
PER RECTAL EXAMINATION :
DIFFERNTIAL DIAGNOSIS :
Depending on site of tumor
NOTE : THESE CASE SHEETS MAY DIFFER FROM ONE PROFESSOR TO ANOTHER
THANK YOU
FOR ANY CORRECTIONS & SUGGESTIONS :
: bandaruprudhvi@gmail.com or 8121314003
