MORBID OBESITY

MODERATOR: DR. NISHTHA

PRESENTERS: DR SAI LAKSHMI
DR GURSHARAN
HISTORY OF PRESENT ILLNESS :

47 YEAR OLD MALE, BUSINESSMAN BY PROFESSION AND RESIDENT OF FARIDABAD, PRESENTED TO SAFDARJUNG HOSPITAL.

CHIEF COMPLAINT : PAIN IN ABDOMEN X 1 YEAR

PATIENT WAS APPARENTLY WELL UNTIL 1 YEAR AGO,WHEN HE STARTED TO DEVELOP PAIN IN THE RIGHT UPPER ABDOMEN WHICH WAS

SUDDEN IN ONSET AFTER CONSUMPTION OF A HEAVY MEAL ,COLICKY IN NATURE ,NON-RADIATING , WHICH WAS RELIEVED ON TAKING

MEDICATIONS AND AGGRAVATED ON TAKING MEALS.FREQUENCY OF SYMPTOMS INCREASED WHICH PROMPTED THE PATIENT TO SEEK

CONSULT.
PAST HISTORY

COMORBIDITIES :

(+) HYPERTENSION DISORDER SINCE PAST 1 YEAR ,ON TAB AMLODIPINE 5MG ,COMPLIANT AND TAKES REGULAR
CONSULTATION IN SAFDARJUNG HOSPITAL FOR THE SAME.

(-)THYROID DISORDER: NO CONSTIPATION,DRY SKIN ,COLD INTOLERANCE , MUSCLE CRAMPS,DRY COARSE HAIR,SWELLING OF
LEGS .

(-)DIABETES MELLITUS: NO POLYDIPSIA, POLYLURIA, NOCTURIA, FREQUENT FUNGALIFECTIOS OR RECURRING CONJUNCTIVAL,

GUM OR URINARY TRACT INFECTIONS ,TINGLING AND NUMBNESS IN LEGS ,SLOW HEALING OF CUTS OR WOUNDS.

(-)TRANSIENT ISCHEMIC ATTACK (-) STROKE,(-) SEIZURES

(-) TB, (-) ASTHMA, (-) EMPHYSEMA

(-) JOINT PAIN,

(-) ALLERGY OR PROLONGED HOSPITALIZATION IN THE PAST.

NO SURGICAL HISTORY.
PAST HISTORY

(+) GRADUAL STORY OF WEIGHT GAIN IN LAST 6 YEARS FROM 65KG TO 95KG AFTER STARTING HIS OWN BUSINESS.

SLEEP HISTORY:

6 HRS A DAY (+) DAY TIME TIREDNESS,(+) USE OF 3 PILLOWS BELOW FOR SLEEP ,(+) SLEEPS IN SEMI RECUMBENT POSITION,(+) OBSERVED
SNORING.

(-)SUDDEN AWAKENING DURING SLEEPING. (-)TRANSIENT APNEOIC EPISODES

(-)HEAVINESS IN HEAD OR HEADACHE

(-) INTAKE OF SEDATIVES, ANTIDEPRESSANTS OR ANXIOLYTICS

(-)SINUSITIS/NASAL CONGESTION,DEVIATED NASAL SEPTUM,ENLARGED TONSILS OR ALLERGIES.

DIETARY HABITS :

(-) WEIGHT REDUCTION DIET

FAMILY HISTORY :

MATERNAL : (+) HTN

PATERNAL : (+) HTN

PERSONAL HISTORY :

• MARRIED MALE

• BELONGS TO UPPER MIDDLE CLASS SOCIO-ECONOMIC STATUS ACCORDING TO MODIFIED KUPPUSWAMI SCALE.

• NON SMOKER

• CHRONIC ALCOHOLIC FOR PAST 40 YEARS, CONSUMING AN AVERAGE OF 100 ML PER DAY.

• NON-VEGETARIAN BY DIET.

• NORMAL APPETITE, BOWEL AND BLADDER HABITS.

• HISTORY OF DISTURBED SLEEP, WITH DAY TIME TIREDNESS PRESENT.

DRUG HISTORY

PATIENT IS CURRENTLY ON: TAB AMLODIPINE 5MG OD

PATIENT IS COMPLIANT TO TREATMENT.

PROVISIONAL DIAGNOSIS

47YEAR OLD MALE WHO PRESENTED TO SJH WITH CHIEF COMPLAINT OF RIGHT UPPER QUADRANT PAIN ASSOCIATED WITH
INTAKE OF HEAVY MEAL AND AGGRAVATED BY SAME WITH A PROVISIONAL DIAGNOSIS OF CHOLELITHIASIS WITH K/C/O
HYPERTENSION ON REGULAR MEDICATION WITH MODERATE OBESITY.
EXAMINATION

PT WAS EXAMINED IN A WELL LIT ROOM AFTER TAKING DUE CONSENT. HE WAS SITTING COMFORTABLY
ON BED AND WAS CONSCIOUS AND ORIENTED TO TIME, PLACE AND PERSON.

PT HAD A OBESE BUILT

WEIGHT: 127 KG

HEIGHT: 170 CM

BMI: 43.9 KG/M2

GENERAL PHYSICAL EXAMINATION: NO PALLOR, ICTERUS, CYANOSIS, CLUBBING LYMPHADENOPATHY,

PERIPHERAL EDEMA.

JVP WAS NOT RAISED.

SPINE APPEARS NORMAL

PULSE: 71/MIN, MEASURED IN RIGHT RADIAL ARTERY IN SITTING POSTURE
REGULARLY REGULAR
GOOD VOLUME
NO RADIO-RADIAL OR RADIO-FEMORAL DELAY
ALL PERIPHERAL PULSES WERE PALPABLE

BLOOD PRESSURE: 131/99 MMHG, MEASURED IN RIGHT ARM WITH APT SIZE CUFF IN
SUPINE POSITION AT THE LEVEL OF HEART

RESPIRATORY RATE: 14/MIN

REGULAR
ABDOMINAL
NO USE OF ACCESSARY MUSCLE OF RESPIRATION

TEMPERATURE: AFEBRILE TO TOUCH

AIRWAY EXAMINATION: NO VISIBLE FACIAL DEFORMITY

MOUTH OPENING > 3 FINGERS

MODIFIED MALLAMPATI GRADE 3

INADEQUATE NECK FLEXION AND ATLANTO-AXIAL EXTENSION

ADEQUATE JAW MOVEMENTS

THYRO-MENTAL DISTANCE: 5.5 CM

GOOD ORAL HYGIENE

SUBMENTAL FAT PRESENT

STOP BANG-

S- SNORING- YES

T- TIRED- DAYTIME TIRESNESS- YES

O- OBSERVED CHOOKING/GASPING DURING SLEEP- NO

P- PRESSURE- BEING TREATED FOR HTN- YES

B- BMI> 35KG/M2- YES

A- AGE>50- NO

N- NECK CIRCUMFERENCE>17” IN MALE/ >16” IN FEMALES- YES

G- GENDER- MALES-YES
SYSTEMIC EXAMINATION

CVS:

INSPECTION: NO OBVIOUS DEFORMITY

APICAL IMPULSE VISIBLE

NO ENGORGED VEINS/SCAR/SINUSES VISIBLE

PALPATION: FINDING OF INSPECTION WERE CONFIRMED

APEX BEAT PALPABLE IN 5TH INTERCOSTAL SPACE, 1 CM LATERAL TO MIDCLAVICULAR LINE

NO PALPABLE THRILL/ PARASTERNAL HEAVE

NO PULSATIONS IN ANY OTHER AREA

AUSCULTATION: AUSCULTATED IN MITRAL, AORTIC, TRICUSPID AND PULMONARY AREA.

RATE: 80/MIN, REGULAR

S1 AND S2 PRESENT. NO MURMUR HEARD IN ANY AREA

RESPIRATORY SYSTEM:

INSPECTION: NO GROSS ABNORMALITY OF NASAL, ORAL CAVITY AND CHEST.

RR- 14/MIN, REGULAR, ABDOMINO-THORACIC

B/L CHEST EXPANSION EQUAL

NO USE OF ACCESSARY MUSCLES OF RESPIRATION

PALPATION: FINDINGS OF INSPECTION WERE CONFIRMED

NO LOCAL TENDERNESS OR RISE IN TEMP

B/L CHEST MOVEMENTS EQUAL

VOCAL FREMITUS COMPARABLE

PERCUSSION: B/L RESONANT NOTE

AUSCULTATION: B/L AIR ENTRY +

CLEAR

NORMAL VESICULAR SOUND +

ABDOMINAL EXAMINATION:
- GAURDING +
- TENDER IN RIGHT HYPOCHONDRIAC REGION
- NO DISTENSION
- UMBILICUS MIDLINE AND EVERTED
- NO ORGANOMEGALY
- BOWEL SOUNDS +

CNS EXAMINATION:
- CONSCIOUS, ORIENTED TO TIME, PLACE AND PERSON
- HIGHER MENTAL FUNCTION INTACT
- B/L POWER IN UPPER AND LOWER LIMBS: 5/5
- NO CEREBELLAR SIGNS
- REFLEXES NORMAL
SUMMARY:

PATIENT IS A 44 YEAR OLD MALE WHO PRESENTED TO SJH WITH CHIEF COMPLAINT
OF RIGHT HYPOCHONDRIAC REGION PAIN, INDIGESTION AND VOMITING SINCE 2
WEEKS HAS A DIAGNOSIS MOST LIKELY OF CHOLECYSTITIS WITH K/C/O
HYPERTENSION, DIABETES MELLITUS ON REGULAR MEDICATION AND MORBID
OBESITY.
INVESTIGATION:

- RBS: 106MG/DL

- HB/12.3GM/DL

- TLC-3700/MM3

- PLATELET – 134000/MM3

- KFT -15/0.8

- NA/K -134/4.1

- INR -1

- URINE R/M: WNL

- CXR: WNL

- USG WHOLE ABDOMEN- GALL BLADDER DISTENDED WITH CALCULUS OF SIZE 16MM AT NECK WITH MUCH IDLE
OF GALL BLADDER.
END