2. • Mr. Irfan , 68 years, Male, Carpenter, Muslim
• Lower socio-economic strata
• Resident of Ghaziabad, UP
• Presented to Surgery OPD with
- Upper abdominal pain for last 4 months
- Intermittent vomiting for last 4 months
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3. H/o present illness:
Pain:
• Started at right upper abdomen & radiating to right upper back
• Sudden onset, colicky & gradually increased in intensity
• Associated with burning sensation in epigastrium, and vomiting
• Aggravated on coughing & spicy meal
• Relieved after vomiting and medications
• Had 3 similar episodes in last 4 months (last one 7 days back)
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4. H/o present illness:
Pain was not associated with:
• Physical activity
• Any particular posture
• Fever
• Diurnal variation
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5. H/o present illness:
Vomiting:
• Sudden onset, episodic, non-projectile, scanty
• Associated with feeling of fullness of upper abdomen & pain
• No blood or coffee coloured content
• Not associated with vertigo or headache; not related to food intake
• Relieved with certain medications
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6. H/o present illness:
There was no:
• Yellowish discoloration of eyes or urine
• Loss of appetite
• Weight loss
• Alteration of bowel and bladder habit
• Passage of black or clay coloured stool
• Bleeding from any site
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7. H/o present illness:
Shortness of breath (SOB) on exertion & intermittent coughing for 5 years
• SOB:
- Gradual onset, progressive
- Aggravated by strenuous work & cough
- Relieved on rest
- Not associated with noisy respiration, chest pain, swelling of face/lower limbs
- No h/o awakening from sleep
- No postural, diurnal or seasonal variation
- Uses inhalers regularly for the same
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8. H/o present illness:
• Intermittent coughing:
- Gradual onset
- A/w scanty whitish sputum production (No blood)
- Not aggravated by dust, fumes, cold air or specific posture
- Relieved spontaneously
-No seasonal or diurnal variation
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9. H/o present illness:
• In 2017, had complaints of severe shortness of breath & cough and was
admitted in a government hospital in Ghaziabad
• Treated in general ward with oxygen, injections and nebulization
• Discharged on inhalers, 2 puffs once daily
• Has not visited any doctor for last 2 years
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10. Past history:
No H/O
• Jaundice
• Tuberculosis, Recurrent chest infection
• Diabetes /Hypertension/Heart disease
• Anaesthesia/Surgery
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11. Personal history:
• Studied till class VI; Carpenter
• Married 35 years ago; Has 4 children
• Non vegetarian & Non-alcoholic
• Bidi smoker for 40 years, 2 packs/day
• Quit smoking 2 years back
• Normal bowel & bladder habit; Normal sleep pattern
• No known allergy 11
12. Family history:
• Pulmonary tuberculosis – Wife (12 years back)- Treated
• No H/o similar or any other chronic illness
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13. Treatment history:
• Underwent blood tests and a test with a machine where he was asked to
blow through a pipe.
• One inhaler, 2 puff twice daily and some analgesics
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14. On general examination:
• Conscious & oriented to time, place & person; lying comfortably on bed
• Height- 175 cm; Weight- 65 kg; Afebrile
• PR- 96/ min (Regular, good volume, normal character, no RR or RF delay)
• BP- 110/70 mm-Hg (in right arm in supine position)
• RR- 18/min ( Regular, abdomino-thoracic)
• No Pallor, edema, cyanosis, clubbing, icterus or lymphadenopathy
• Jugular venous pressure- not raised
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15. Gastro-intestinal (GI) system:
Upper GI tract:
• Blackening of lips & gums
• Brown stain on teeth
• Tongue, buccal mucosa, palate, tonsil and posterior pharyngeal wall
looks healthy
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16. Gastro-intestinal (GI) system:
Abdominal examination:
1. Inspection:
• Scaphoid & uniformly moving with respiration
• Umbilicus inverted, midway between xiphisternum & pubis
• No visible scar, pigmentation, ulcer, venous prominence, swelling, pulsation or movement
• No visible localized impulse on coughing
• Genitals- healthy
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17. Gastro-intestinal (GI) system:
Abdominal examination:
2. Palpation:
• Normal temperature and soft on touch
• Tender epigastrium and right hypochondria
• Abdominal girth at umbilicus level- 86 cm
• No muscle guarding, lump, pulsation, fluid thrill, rebound tenderness or organomegaly
• No palpable cough impulse over inguinal region, urinary bladder non palpable
• Scrotum & testicles- normal
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18. Gastro-intestinal (GI) system:
Abdominal examination:
3. Percussion:
• Normal tympanic note
• No shifting dullness
• Upper border of liver at right 7th intercostal space (ICS) at mid clavicular line (MCL)
4. Auscultation:
• Normal intestinal peristaltic sounds audible; 5 per minute
• No hepatic or splenic rub
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19. Respiratory system:
Upper respiratory tract:
• External nares- normal; No nasal flare; Non-tender maxillary or frontal air sinus
Thoracic examination:
1. Inspection:
• No tracheal deviation, both nipples are at same level
• Bilateral equal movement with breathing
• No visible swelling, venous prominence, pulsation, scar or ulcer over chest & back
• No wheeze or stridor
• Not using accessory muscles of respiration 19
20. Respiratory system:
Thoracic examination:
2. Palpation:
• Normal temperature
• No tenderness, bony deformity
• Bilateral equal movement of chest wall with breathing
• Trachea in midline
• Chest expansion on full inspiration- 3 cm
• Diameter (at nipple level): Antero-posterior 36 cm; Transverse 42 cm
• Vocal fremitus normal on both the sides
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21. Respiratory system:
Thoracic examination:
3. Percussion:
• Resonant in all areas in sitting position
• Upper border of liver dullness in right 7th ICS
• Cardiac dullness could not be located
4. Auscultation:
• Bilateral vesicular breath sounds in all areas
• Rhonchi bilaterally in all areas; no crepitations or other added sound present
• Vocal resonance- normal 21
22. Cardio-vascular system:
1. Inspection: No visible abnormality
2. Palpation:
• Apex beat at left 5th intercostal space, 2 cm medial to MCL;
• No palpable thrill/para sternal heave
3. Auscultation-
• Normal heart sounds audible
• No murmur, hum, bruit or rub
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23. Nervous system:
• Higher functions are intact
• Cranial nerves are all normally functioning
• Built, tone, power, co-ordination of all the motor units are normal
• All sensory functions and reflexes are intact
• Cerebellar and autonomic functions are normal
• Gait is normal
• No trophic changes and no tender peripheral nerves
• Vertebral column- No deformity, non tender and all movements are normal
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24. Airway examination:
• Bearded
• Upper incisor length- 1cm; No buck teeth; Inter-incisor gap- 4.5 cm
• Palate- Not arched or narrow
• Modified Mallampati class- 2
• Upper lip bite test- Class I
• Thyromental distance- 7 cm
• Submandibular compliance- soft on palpation
• Neck circumference- 28 cm, Neck ROM- > 90⁰ 24
25. Bed side PFT:
• Laryngeal height: 6 cm
• Forced expiration time: 4 seconds
• Sabrasez breath holding time: 20 seconds
• Single breath count test: 22
• Schneider’s match blow test: at 15 cms
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30. Ultrasound of whole abdomen
• Chronic calulous cholecystitis with multiple small calculi within
the gall bladder
• CBD- normal
• Grade 1 fatty changes in liver
• Rest- WNL
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