55yr old female with swelling in right leg below the gluteal region


 This is an online e log book to discuss our patient deidentified health data shared after taking his/her/guardians signed informed consent.                                                                         Here we discuss our individual patient’s problem through series of inputs available global online community of experts with an aim to solve those patient’s problems with collective current best evidence based inputs                                                                                                                                                                 CHIEF COMPLAINT                                                                Swelling below right gluteal region                                               Numbness in the leg                                 

HISTORY OF PRESENT ILLNESS                                         Patient was apparently asymptomatic one month ago then she developed a swelling below the gluteal region                             Not progressive,not associated with pain but have numbness in the leg                               

HISTORY OF PAST ILLNESS                                                 Not known

PERSONAL HISTORY                                                              Married                                                                                        Occupation: farmer                                                                           Apetite: normal                                                                                Bowels:regular                                                                              Diet:mixed                                                                                     Micturition: normal 

FAMILY HISTORY                                                                     Not significant 

SYSTEMATIC  EXAMINATION                                             Cardiovascular system                                                                   Thrills: no                                                                                      Cardiac sounds:S1 S2                                                                 Cardiac murmurs : no      

RESPIRATORY SYSTEM                                                           Dyspnoea: no                                                                                  Wheeze:no                                                                                     Position of trachea: central         

ABDOMEN                                                                                   Shape of abdomen:scaphoid                                                          Tenderness:no                                                                               Palpable mass:no                                                                           Hernial orifice : normal                                                                 Liver: not palpable                                                                         Bowel sounds: yes

CNS                                                                                               Level of consciousness: alert                                                         Speech : normal 

PHYSICAL EXAMINATION  

Bp:120/80mm hg                                                                                                                                                                  Pulse rate: 74/min                                                                                  Respiration rate: 18/min                                                                No pallor,edema                                                                            Temperature:98.7F

FINDINGS: a well defined hyperchoiec lesion with no vascularity can be seen in the  right gluteal region in subcutaneous plane with no deeper extensions 

PROVISIONAL DIAGNOSIS 

LIPOMA  OVER RIGHT GLUTEAL REGION                  

MEDICATION:                                                                             T.UIT C PO/OD                                                                             T.MUT PO/OD 

 Discussion: patient was advised to have a surgery        













            

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