Name: Aselefech Mihretu

Age: 70

Sex: female

M/S: widowed

Address: Addis Ababa

Edu: no formal education

Occupation:

Religion: Orthodox Christian

Previous admission: Cholecystectomy done 15yrs ago at Zewditu hospital

Hx taken from: patient, reliable

CC: Epigastric and RUQ abdominal pain of 1 week duration

This a 70yrs old female patient who was relatively well who presented with the above cc. The epigastric
pain started a week ago and gradually worsened over time. It is characterized as constant burning type
of pain that doesn’t radiate to other part of the body. It was graded as moderate in severity. No
alleviating/aggravating factor was identified. This was ____days later followed by RUQ abdominal pain.
The RUQ abdominal pain was continuous stabbing in character, it has no radiation and was graded as
moderate. It was aggravated by change in position (lying on her right side).

She also has associated multiple episodes of vomiting of ingested matter (initially) which later became
bilious. It followed each intake of food. She has nausea, loss of appetite and fatigue. She also has
unquantified weight of loss in the past 1 month. Her clothes are loose.

She was treated for PUD 1 year back at MCM hospital. At the time she presented with epigastric burning
pain/dyspepsia. She was told to have H.Pylori infection and was given Syrup and unspecified oral tablets.
Her endoscopy result was normal. The dyspepsia resolved after the treatment. She experiences is it
when she eats _______ meal.

Otherwise she doesn’t have hx of fever, chills, headache, diarrhea, constipation, bloating, abdominal
distension, blood per rectum, melena, bloody vomit, difficulty of swallowing. No history of Jaundice,
stool color change, itching. No contact to a known hepatitis patient, no blood transfusion, no needle
prick injury, no travel history. No myalgia, arthralgia, skin rash, ABM, confusion or change in mentation.

She doesn’t have cough, SOB, exertional dyspnea, chest pain, orthopnea, PND, intermittent claudication.
No known cardiac illness, DM, HTN, dyslipidemia. No history of contact to a known TB patient or
chronically coughing patient. No dysuria, urgency, frequency, nocturia, change in urine color. No history
of Steroid uses, trauma to the abdomen, hypertriglyceridemia, ERCP procedure.

No history of NSAID medication use. She doesn’t smoke or drink alcohol.

PHYSICAL EXAM:
G/A: ASL
Vital signs
BP: 150/80mmHg, taken from the Right brachial artery at supine position

HR: 108bpm, regular and full in volume, taken from the radial artery

RR: 20 per minute, nml pattern and rhythm.

T: 36.5 C from axilla
SpO2: 92% at Room air

Waist circumference:

BMI:

HEENT:
Head: atraumatic, normocephalic
EYES: pink conjunctiva, no icteric sclera
EARS: no swelling or discharge, no mastoid or tragus tenderness
Nose: no epistaxis, no discharge, no sinus tenderness

Mouth: wet buccal mucosa , tongue, teeth, throat________

Neck—Trachea midline. Neck supple;

Lymphoglandular system—No preauricular, postauricular, occipital, submandibular, submental, anterior

and posterior cervical, supraclavicular and axillary lymphadenopathy
Inguinal LN not done.
thyroid isthmus palpable, lobes not felt.

Breast was not palpated

CHEST:

Inspection:

She has normal depth and pattern of breathing. No finger clubbing, no central cyanosis.

Chest is symmetrical.

No visible deformity, use of accessory muscles (sternocleidomastoid, intercoastal muscles). No

sub costal retraction.

Palpation:

No tenderness, trachea is in the midline

Tactile fremitus is bilaterally felt equal

 Symmetric chest expansion

Excursion: not done

Percussion

Resonant all over

Auscultation

Clear air entry bilaterally. Vesicular breath sound heard

Cardiovascular system

Arterial: Carotid, radial, Brachial, femoral, popliteal, posterior tibialis and dorsalis pedis felt bilaterally
symmetrical.

No carotid bruits

Venous:

JVP: not raised, hepatojugular reflex- not done(painful)

Precordial examination

Inspection: quiet precordium, no visible apical pulsation

Palpation: No heaves or thrills

PMI: felt at 5th ICS, at the midclavicular line

Auscultation: S1 & S2 well heard.

No murmur, gallop or added heart sounds (S3 & S4).

Abdomen:

Inspection: protuberant abdomen that moves with respiration, inverted umbilicus, no visible
dilated veins, peristalisis. She has surgical scar 8cm at the RUQ(kocher incision)

Auscultation: Normoactive bowel sounds. No renal bruits appreciated

Palpation: She had mild-moderate epigastric and RUQ tenderness.

Liver: 8cm in size

Spleen: impalpable (in the traubes space)

Percussion: tympanic throughout

PR: not done

GU: NO CVA, suprapubic tenderness, Kidney and bladder not palpable

MSK: Grade 1 pretibial edema bilaterally. No prominent veins. No calf tenderness. No lesions on the
foot.
 SKIN: no skin lesion

Nails: no clubbing of fingers or splinter hemorrhage.

NEUROLOGIC EXAM:

COTPP. No meningeal signs

Cranial nerves: Grossly intact(2,3,4,6,7, 9 and 10 assessed and Nml)

Motor:

Inspection: no abnormal body movement, no spontaneous and triggered fasciculation.

Bulk: comparable muscle bulk on both UL and LL. no atrophy

Tone: normotonic

Power: 5/5 on all (upper and lower) right and left extremities.

Deep tendon Reflexes

Biceps Triceps Brachioradialis Patellar(knee) Ankle Babinski(plantar)

Lt +2 +2 +2 +2 1 Down going

Rt +2 +2 +2 +2 1 Down going

Assessment: dyspepsia secondary to PUD

R/o Viral Hepatitis, Liver abscess, Acute Pancreatitis, Inferior wall MI, GI
malignancy, cholangitis, Lower lobe pneumonia

Investigations

1. Abdominopelvic US: Nml(post cholecystectomy)

2. CXR: nml
CBC
WBC Hg Hct Plt MCH MCV RDW Neut Eos Bas Lym Mon
5270 13.7 36.5 415000 29 37 13 83% - - 10.1% Mixed 7.6

Electrolyte: Na-139 K-4.9 Cl-99

RFT: Cr-0.7 BUN: 12

 LFT
Bil D [0- Bil T(0.2- T.prot(6.3- Alb 3.5-5 GOT SGPT ALP GGT
1.1] 1.3) 8.2)
April 15 2.1(H) 4.9H 6.2(H) 3.7(N) 527(11x) 605(8x) 268(2x) 337
(5x)
April 17 0.5 1.1 5L 2.7L 99(2x) 286(4x) 173(1.5x) 238(4x)

Troponin: <0.01

Amylase: 50 nml

Lipase: 164 nml

Anti Hep C Ab

HbSAg: