Case based discussion

Dr. BISWAJIT JENA

• Mr. Anil Behera , 68 years, Male, Carpenter, Hindu

• Lower socio-economic strata

• Resident of Ganjam, Odisha

• Presented to Surgery OPD with

- Upper abdominal pain for last 4 months

- Intermittent vomiting for last 4 months

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 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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 H/o present illness:
Pain was not associated with:
• Physical activity
• Any particular posture
• Fever
• Diurnal variation

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 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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 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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 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 7

 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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 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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 Past history:

No H/O
• Jaundice
• Tuberculosis, Recurrent chest infection
• Diabetes /Hypertension/Heart disease
• Anaesthesia/Surgery

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 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
 Family history:

• Pulmonary tuberculosis – Wife (12 years back)- Treated

• No H/o similar or any other chronic illness

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 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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 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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 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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 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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 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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 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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 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
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 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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 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
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 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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 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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 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
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 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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 Provisional diagnosis

Mr. Anil, 68 years old male with upper abdominal pain under
evaluation with chronic lung disease

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 Differential diagnosis

• Chronic cholecystitis

• Peptic ulcer disease

• Gastro-esophagial reflux disorder

• Chronic pancreatitis
• Hiatus hernia

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Investigations?

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 Investigations:
• Hemoglobin: 15.5 gm %
• TLC: 6800/cu.mm (N64 L30 M3 E3)

• Platelets: 1.6 lacs/cu.mm

• Urea: 22; Creatinine: 0.8; Na+: 138; K+: 4.5; Blood sugar- 109 mg/dl (R)
• Total bilirubin: 0.8 mg/dl
• Total protein: 7.0 gm/dl; Albumin: 3.5 gm/dl

• SGOT/SGPT: 21/37 IU/L, ALP: 82 IU/L

• Urine (routine & microscopy)- Within normal limit 29
 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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Chest X-Ray

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ECG 12 lead

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Pulmonary function test

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 Final Diagnosis:

Mr. Anil, 68 year old male with Chronic calculous cholecystitis

with Chronic obstructive pulmonary disease

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