45 year old female with cavernous hemangioma

CASE OF A 45 YEAR OLD FEMALE WITH CAVERNOUS HEMANGIOMA

** This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

Note: This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Here, in this series of blogs, we discuss our various patients' problems through series of inputs from available global online community of experts with an aim to solve those patients' clinical problems, with collective current best evidence based inputs.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end.

 
I have been given the following case to solve, in an attempt to understand  the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings,  Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.

CASE SHEET

Chief complaint:  Painful swelling on occiput/lower neck since the past 2 months

A swelling on upper back since past 1 week. 

History of presenting illness: The patient was asymptomatic for the past 6 years. 

6 years back patient noticed a swelling at the base of her neck. She did not seek medical attention since it was painless. 

2 months ago the swelling became painful and upon putting pressure on the swelling patient complained of dizziness and blurring of vision.

 As the symptoms started bothering her she visited a hospital in Siliguri where some painkillers were prescribed to her, she however does not recall the name of these medicines. 

The swelling has increased in size. 

One week back patient developed a swelling on her lower back it is not tender to touch nor painful as is.

History of past illness: There is no significant history if past illness, no similar complaints. 

No history of Diabetes, CAD, Asthma, TB or epilepsy. 

Patient has Hypertension. 

Drug history:  Medication for Hypertension is prescribed but the patient does not remember the name of drugs. 

Personal history: Patient is married and is a farmer by occupation. She came to the hospital accompanied by her elder brother who is her attender. 

Appetite is normal

Diet is of mixed type

Regular bowel and bladder 

There is no history of any alcohol or drug consumption. 

Family history:  No relevant family history

General examination:

Patient is conscious, coherent and cooperative. She is well oriented to place,time and people. 

Pallor: Absent

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Koilonychia: Absent

Lymphadenopathy: Absent

Edema: Absent

Vitals:

Temperature: afebrile

Respiratory rate: 10 breaths per minute

Pulse : 110 per minute

Examination of the swelling:

Situation: Occiput

Shape: Raised , rectangular

Size: 6×5 cm

Surface: Smooth

Edge: No distinct edge. Smooth margins

Temperature: slight increase

Consistency: Uniform. Soft swelling

Compressibility: present

Reducibility: Absent

CVS examination:

S1 and S2 are heard. No murmurs are heard

Respiratory system examination:

 No vesicular sounds are heard

Per abdomen: Tender.No palpable mass, fluid. No palpable spleen or liver. 

CNS examination:

Patient is conscious and coherent. She is cooperative and oriented to space, time and people. 

Cranial nerves are intact

Speech is normal

Gait is normal

Motor and sensory system normal

No finger nose or knee heel incoordination. 

Diagnosis: Cavernous 

Treatment: Embolization