LONG CASE SURGERY Rafid Vai

LONG CASE
GENERAL SURGERY
Compiled by
RAFID AZIZ CHOWDHURY
©JRRMC-22©
JALALABAD RAGIB- RABEYA MEDICAL COLLEGE

CONTENTS
Topic Page number
Chronic cholecystitis 2-6

Renal stone 7-10
Benign enlargement of prostate 11-15
(BEP)
Gastric outlet obstruction (GOO) 16-20
Obstructive Jaundice 21-25
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CHRONIC CHOELCYSTITIS
 Particulars of the Patient:-

Name:- Mrs. X
Age:- 40 years
Sex:- Female
Religion:- Muslim
Occupation:- House wife
Marital status:- Married
Present address:- Golapganj, Sylhet
Permanent address:- Golapganj, Sylhet
Date of admission:- 05.03.2021
Date of examination:- 05.03.2021
 Chief Complaints:-
1. Recurrent pain in the right upper abdomen for 6 months.
 History of present illness:-

According to the statement of the patient, she was reasonably well 6 months back., then
she felt pain in the right upper abdomen which was sudden in onset. The pain was colicky in
nature, severe in intensity, aggravated by taking fatty food & was relieved by analgesics.
The pain referred to the tip of the right shoulder & radiated to the back of right side. The
patient has similar attacks of pain for last 6 months initially at an interval of 3-4 months, but
for last one month, patient is having dull aching constant pain in the right upper abdomen.
The pain has no periodicity. It is occasionally associated with nausea & vomiting. There is
no history of jaundice, fever with chills & rigor. The patient also complains of flatulence,
dyspepsia & sensation of fullness after meals for the same duration. His bowel & bladder
habit are normal. There is no history of hemoptysis, chest pain, anorexia, weight loss, bone
pain.
With these complaints, she got admitted to the hospital for better management.
 History of Past illness:- Is there any H/O DM, HTN, TB

 Past medical History:- Is there any H/O any surgery or any disease for which patient was
hospitalized previously.
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 Drug history:- If the patient took any medication for this illness. Ask if he/she could
mention the name. Any H/O taking Aspirin, Clopidogrel, Warfarin.
 Family history:- Ask if all the family members are alive & healthy?
 Personal history:- Ask if the patient is smoker or betel nut chewer?
 Socio-economic history:- Ask if he lives in a mud house/building, drinks from tubewell
water or not? Write accordingly
 Immunization history:- If completely immunized according to EPI schedule or not?
 Allergic history:- Is there any H/O allergy to any food/drugs.
 Menstruation history:- :- (In case of female, you must enquire about the menstrual cycle. Is
it regular or not? Write it accordingly)
 General Examination:-
Appearance:-
Body built:-
Co-operation:-
Decubitus:-
Nutritional status:-
Anaemia:-
Jaundice:-
Cyanosis:-
Oedema:-
Dehydration:-
Clubbing:-
Koilonychia:-
Leuconychia:-
Pulse:-
Blood pressure:-
Respiratory rate:-
Temperature:-
Lymph node:-
Thyroid gland:-
 Local Examination of Abdomen:-

Inspection:-
1. Shape & contour of the abdomen:- Normal/Scaphoid/Distended
2. Whether moves with respiration/not
3. Flanks:- Full or not
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4. Umbilicus
 Centrally placed/not
 Inverted/Everted
5. There is no visible swelling, ulceration, discharge, sinus, engorged veins or scar
mark present
6. Hernial orifices- intact or not?
Palpation:-
 Superficial palpation
 Any superficial tenderness
 Muscle guard & rigidity
 Deep palpation
 Any tenderness?
 Palpation of liver, spleen & kidneys.
 If any visible swelling, then palpation of the swelling.
 Murphy’s sign?
Percussion:- Percussion note is Tympanitic

Auscultation:- Bowel sound is present.
 Respiratory system:- Reveals no abnormalities.

 Cardiovascular system:- Reveals no abnormalities.
 Nervous system:- Reveals no abnormalities.
 Salient feature:-
Mrs. X, 40 years old, non-diabetic, normotensive female hailing from Golapganj, Sylhet
admitted to this hospital with the complaints of recurrent pain in the right
hypochondrium for 6 months. The pain was colicky in nature, severe in intensity,
aggravated by taking fatty food & was relieved by analgesics. The pain referred to the tip of
the right shoulder & radiated to the back of right side. The patient has similar attacks of
pain for last 6 months initially at an interval of 3-4 months, but for last one month, patient is
having dull aching constant pain in the right hypochondrium. The pain has no periodicity.
It is occasionally associated with nausea & vomiting. There is no history of jaundice, fever
with chills & rigor. The patient also complains of flatulence, dyspepsia & sensation of
fullness after meals for the same duration. There is no history of Haematemesis, Melena,
Per rectal bleeding, Haematuria, anorexia, weight loss, cough, Haemoptysis, chest pain,
bone pain.
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On general examination, she is non-anaemic, non-icteric, Pulse is ___beats/min, Blood
pressure is ___mmHg, Temperature is ____ ⁰ C, Respiratory rate is _____breaths/min.
On inspection of abdomen, abdomen is normal in shape, moves with respiration, umbilicus
is inverted. There is no visible swelling, ulceration, discharge, sinus, engorged veins or scar
mark present. There is no history of hemoptysis, chest pain, anorexia, weight loss, bone
pain. Hernial orifices are intact.
On palpation, abdomen is soft, non-tender, murphy’s sign is negative, and no
organomegaly is present. Percussion note is tympanitic. On ausculation, bowel sound is
present.
Other system reveals no abnormalities
 Provisional diagnosis:- Chronic calculous cholecystitis
 Differential diagnosis:-
Disease Points in favour Points in against

 Chronic Duodenal Ulcer I. Pain in the right upper I. No periodicity of pain
abdomen II. Pain aggravated by taking
fatty food
III. Pain is not relived by
antiulcerant
 Chronic pancreatitis I. Pain in the right upper I. Pain was dull aching in
abdomen nature
II. Pain not relieved by
leaning forward
III. Pain aggravated by taking
fatty food
IV. Patient is not emaciated.
 Investigation:-
 For Diagnosis:-
1. Ultrasonography of whole abdomen with special attention to hepatobiliary
system & pancreas.
2. Liver function test:-
- S. bilirubin
- ALP
- Prothombin time
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- SGPT SGOT
3. Plain X-ray abdomen (as 10% radio-opaque)
4. Upper GI endoscopy (to exclude D/D)
5. Serum amylase, lipase (to exclude D/D)
 For General Anaesthesia fitness:-

1. Complete blood count
2. Blood grouping & Rh typing
3. Random blood sugar
4. Serum creatinine
5. Urine RME
6. Chest X-ray
7. ECG
 Confirmatory Diagnosis:- Chronic Calculous Cholecystitis
 Treatment:- Laparoscopic Cholecystectomy under General Anaethesia
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RENAL STONE

Name:- Mr. X
Age:- 40 years
Sex:- Male
Religion:- Muslim
Occupation:- Farmer
Present address:- Golapganj, Sylhet
Permanent address:- Golapganj, Sylhet
1. Recurrent pain in the right loin for 5 months.
2. Passage of blood mixed with urine for 1 month. (if patient complains)

According to the statement of the patient, he was reasonably well 5 months back. Then he
gradually developed pain in right loin which is insidious in onset, fixed & constant dull aching in
nature with no radiation and aggravated by movement specially during climbing stairs and
relieved by taking rest & medications. It was not associated with nausea, vomiting & fever. The
pain had no relation with taking food and the pain has become more severe in last 3 days. He
also complained of passing blood mixed with urine (if patient complains).
(In case of ureteric stone- He felt pain in the right loin which is moderate in intensity, colicky in
nature & radiates to groin, medial aspect of the thigh or tip of the penis- according to patient’s
complain write it down) There is no history of frequency & urgency of micturition. There is no
history of fever with chill & rigor. His bowel habit is normal.
With these complaints, he got admitted to the hospital for better management.
 History of Past illness:-
 Past medical History:-
 Drug history:-
 Family history:-
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 Personal history:-
 Socio-economic history:-
 Immunization history:-
 Allergic history:-
Appearance:-
Body built:-
Co-operation:-
Decubitus:-
Anaemia:-
Jaundice:-
Cyanosis:-
Oedema:-
Dehydration:-
Clubbing:-
Koilonychia:-
Leuconychia:-
Pulse:-
Blood pressure:-
Respiratory rate:-
Temperature:-
Lymph node:-
Thyroid gland:-
 Local Examination of Abdomen & Genitourinary system:-

Inspection:-
1. Shape & contour of the abdomen:- Normal/Scaphoid/Distended
2. Whether moves with respiration/not
3. Flanks:- Full or not
4. Umbilicus
 Centrally placed/not
 Inverted/Everted
5. There is no visible swelling, ulceration, discharge, sinus, engorged veins or scar mark
present
6. Hernial orifices- intact or not?
7. External urethral meatus is normal in size & shape
8. Penis is not deviated
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Palpation:-
 Both the kidneys are not bimanually palpable & ballotable.
 Renal angle tenderness absent (we should write it non tender as tender
indicate pyelonephritis)
 Both the testis & epidydmis are palpable

Mr. X, 40 years old non-smoker, non-alcoholic, non diabetic, normotensive farmer, hailing
from Golapganj, Sylhet admitted to this hospital with the complaints of pain in right loin for
5 months which is fixed & dull aching in nature with no radiation and aggravated by
movement specially during climbing stairs and relieved by taking medications. It was not
associated with nausea, vomiting & fever. The pain had no relation with taking food and the
pain has become more severe in last 3 days. He also complained of passing blood mixed
with urine. There is no history of frequency & urgency of micturition. There is no history of
fever with chill & rigor. His bowel habit is normal.
On general examination, he is non-anaemic, non-icteric, non cyanosed…....
Pulse is ___ beats/min, Blood pressure is ___ mmHg, Temperature is ___⁰C, Respiratory
rate is ___ breaths/min.
On inspecion of abdomen & genitourinary system, abdomen is normal in shape, moves with
respiration, umbilicus is centrally placed & inverted, Hernial orifices are intact, testis &
scrotum are normal in appearance.
On palpation, Renal angles are non-tender. Kidneys are not bimanually palpable &
ballotable. Percussion note is tympanitic, Bowel sound is present.
Other systemic examination reveals no abnormalities
 Provisional diagnosis:- Right sided renal stone

 Right ureteric stone I. Pain in the right loin I Pain has no radiation
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II. Haematuria
 Acute Cholecystitis I. Pain in the right side of the I. Pain is not related to
abdomen taking food
II. Haematuria
 Acute Pyelonephritis I.Pain in the loin I. No fever with chill & rigor
 Investigation:-
 For Diagnosis:-
1. Plain X-ray Kidney, Ureter & Bladder region.
2. Ultrasonography of Kidney, Ureter & Bladder region
3. Intravenous urography
4. Serum creatinine

1. Complete blood count
2. Blood grouping & Rh typing
3. Random blood sugar
4. Urine RME
5. Chest X-ray
6. ECG
 Confirmatory Diagnosis:- Right sided renal stone
 Treatment:-
 Expectant treatment:- (If stone <0.5 cm)
 Operative treatment:-
 Minimally invasive procedure:-
i. ESWL (Extracorporeal shockwave lithotripsy):- <2cm
ii. PCNL (Percutaneous Nephrolihotomy):- >2cm
 Open surgery:- (if stone >0.5cm)
i. Pyelolithotomy
ii. Extended pyelolithotomy
iii. Nephrolithotomy
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BENIGN ENLARGEMENT OF PROSTATE (BEP)

Name:- Mr. X
Age:- 60 years
Sex:- Male
Religion:- Muslim
Occupation:- Farmer
Present address:- South surma, Sylhet
Permanent address:- South surma, Sylhet
1. Increased frequency of micturition at day & night for 9 months.
2. Difficulty in micturition for 6 months
3. Unable to pass urine for 18 hours.
4. Sudden inability to pass urine for 18 hours followed by catheterization 5 days back
(Write only If patient is catheterized)

According to the statement of the patient, he was reasonably well 9 months back. Then he
gradually developed increased frequency of micturition which was initially 4-5 times during the
day & 2-3 times at night but for last 2 months, 10-12 times at day & 6-7 times at night. He had
to wake up from sleep several times for micturition. He also complained of difficulty in
micturation associated with urgency for last 6 months as a form of poor stream, not improved
by straining, associated with hesitancy, intermittency, post micturition dribbling, & sense of
incomplete bladder emptying. But, for the last 18 hours, he was unable to void urine. (If
catheterized, then write, patient was taken to the local hospital/admitted in this hospital & was
diagnosed as a case of benign enlargement of prostate & was catheterized)
He has no history of passage of pus or blood with urine (to exclude the complications), weight
loss, cough, chest pain, or yellow discolouration of eye or skin (to exclude Ca prostate). He has
no history of pain in the suprapubic region ( to exclude bladder stone or bladder neoplasm) & no
history of urethral instrumentation ( to exclude stricture urethra). His bowel habit is normal
With the above complaints he got admitted in this hospital for better management.
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 History of Past illness:-
 Past medical History:-
 Drug history:-
 Family history:-
 Personal history:-
 Socio-economic history:-
 Immunization history:-
 Allergic history:-
Appearance:-
Body built:-
Co-operation:-
Decubitus:-
Nutritional status:
Anaemia:-
Jaundice:-
Cyanosis:-
Oedema:-
Dehydration:-
Clubbing:-
Koilonychia:-
Leuconychia:-
Pulse:-
Blood pressure:-
Respiratory rate:-
Temperature:-
Lymph node:-
Thyroid gland:-
 Local Examination of Abdomen & Genitourinary system:-

Inspection:-
1. Abdomen is normal in shape
2. Moves with respiration
3. Umbilicus is centrally placed & inverted
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4. There is no visible swelling, ulceration, discharge, sinus, engorged veins
or scar mark present
5. Hernial orifices are intact
6. External urethral meatus is normal in size & shape
7. Penis is not deviated
**There is catheter in situ (If catheter is present, must write it)
Palpation:-
 Abdomen is soft and no tenderness present
 Liver, kidney & spleen are not palpable.
 Urinary bladder palpable/not (might be palpable in acute retention of
urine)
 Both the testis & epididymis is palpated normal.

Digital Rectal Examination (DRE):-
 Inspection:- There is no abnormality in the perineal region.
 Palpation:-
 Anal tone is normal/increased
 Prostate is enlarged
 Surface is smooth
 Firm in consistency
 Median sulcus prominent
 Rectal mucosa is free from the prostate
 After withdrawal of fingers, it is not blood stained.

Mr. X, 60 years old non-smoker, non diabetic, normotensive farmer, hailing from South Surma,
Sylhet admitted to this hospital with the complaints of increased frequency of micturition which
was initially 4-5 times during the day & 2-3 times at night but for last 2 months, 10-12 times
at day & 6-7 times at night. He had to wake up from sleep several times for micturition. He
also complained of difficulty in micturation associated with urgency for last 6 months as a
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form of poor stream, not improved by straining, associated with hesitancy, intermittency, post
micturition dribbling, & sense of incomplete bladder emptying. But, for the last 18 hours, he was
unable to void urine.
He has no history of haematuria, pyuria, weight loss, cough, chest pain, or jaundice He has no
history of suprapubic pain & no history of urethral instrumentation. His bowel habit is normal.
On general examination, he is non-anaemic, non-icteric, non cyanosed…....
Pulse is ___ beats/min, Blood pressure is ___ mmHg, Temperature is ___⁰C, Respiratory rate is ___
breaths/min.
On local examination of abdomen & genitourinary system, abdomen is normal in shape, moves with
respiration, umbilicus is centrally placed & inverted, Hernial orifices are intact, testis & scrotum are
normal in appearance & palpated normal. No organomegaly is present. Percussion note is
tymapnitic & bowel sound is present.
On DRE, prostate is enlarged, smooth surface, firm in consistency, median sulcus is prominent, rectal
mucosa is free from the prostate & after withdrawal of fingers, it is not blood stained.
Other system reveals no abnormalities.
 Provisional diagnosis:- Acute retention of urine due to benign enlargement of

prostate./
(If patient comes after catheterization- Benign enlargement of prostate with catheter in
situ)

 Carcinoma prostate I. Obstructive I. No H/O weight loss,
symptoms present Chest pain, bone
II. On DRE- Prostate pain, haemoptysis,
enlarged jaundice
II. On DRE- firm
consistency, medial
sulcus prominent, No
blood stained finger
 Stricture urethra I. Poor stream i. No H/O hesitancy

ii. Cord like feeling in
the urethra not felt
on palpation
iii. On DRE- prostate is
normal
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 Investigation:-
 For Diagnosis:-
1. USG of Kidney, Ureter & Bladder region, prostate with MCC & PVR
2. Uroflowmetry
3. Transrectal Ultrasound (TRUS)
4. Serum Prostate specific antigen
5. Plain X-ray Kidney, Ureter & bladder region

i. Complete blood count
ii. Blood grouping & Rh typing
iii. Random blood sugar
iv. Serum creatinine
v. Urine RME
vi. Chest X-ray
vii. ECG
 Confirmatory Diagnosis:- Acute retention of urine due to Benign enlargement of

prostate
 Treatment:-
Transurethral resection of prostate (TURP) under spinal anaesthesia
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GASTRIC OUTLET OBSTRUCTION (GOO)

Name:- Mr. X
Age:- 60 years
Sex:- Male
Religion:- Muslim
Occupation:- Farmer
1. Recurrent pain in the upper abdomen for 5 years.
2. Vomiting for 1 year.

According to the statement of the patient, he was reasonably well 5 years back., then he
developed pain in the upper abdomen. Initially pain was gradual in onset, mild to moderate
in severity, burning in nature, radiates to back. Pain usually occurs in empty stomach and he
experiences pain at night which awaken him from sleep. The pain is relieved from taking
food & some other medicines. Pain occurs in episode of every 3-4 months & persists for 2-3
weeks & resolves after treatment.
For last 1 year, the pain has increased in frequency & severity, becomes spasmodic in
nature, occurs after taking meal with a sensation of upper abdominal fullness & is relieved
after induced vomiting. For the last 1 year, he has also developed vomiting after taking
food. Vomiting is preceded by nausea, projectile in nature, foul smelling, profuse in
amount, containing undigested food materials, sour in taste, colorless, not mixed with
blood & not bile stained. He experiences a rolling mass in the upper abdomen for last 1
year, that appears usually after taking meal. His appetite is good, but for last 1 year,
because of pain after taking meal, he is afraid of taking food.
He has no history of vomiting of blood, passage of black tarry stool, yellowish discoloration
of eye. He is constipated & his bladder habit is normal
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He has no history of cough, coughing up of blood, chest pain, breathlessness, bone pain or
back pain.
With the above complaints he got admitted in this hospital for better management.
 History of Past illness:- He has no history of Diabetes mellitus, hypertension, bronchial

Asthma
 Past medical History:- He has no history of previous surgery or wasn’t hospitalized for any
illness.
 Drug history:- He took antacids & some other medicines but, he could not mention the
name of the drugs
 Family history:- None of his family members experienced similar disease
 Personal history:- He is smoker, took 15 sticks per day , but doesn’t drink alcohol
 Socio-economic history:- Low socio-economic status. He uses sanitary latrine & drinks tube-
well water.
 Immunization history:- He is immunized according to EPI schedule
 Allergic history:- No history of allergy to any drugs or medicine
Appearance:-
Body built:-
Co-operation:-
Decubitus:-
Anaemia:-
Jaundice:-
Cyanosis:-
Oedema:-
Dehydration:-
Clubbing:-
Koilonychia:-
Leuconychia:-
Pulse:-
Blood pressure:-
Respiratory rate:-
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Temperature:-
Lymph node:-
Thyroid gland:-

Inspection:-
1. Abdomen is scaphoid in shape
3. Mild epigastric distension
4. Flanks are not full
5. Visible peristalsis is present from left to right
6. Umbilicus centrally placed & inverted
7. Hair distribution normal
9. No visible scar mark or engorged superficial vein.
Palpation:-
 No tenderness, muscle guard or rigidity
 No palpable mass
 Liver, spleen, kidneys are not palpable
 Succusion splash is present
Percussion:-
 Tympanitic all over the abdomen
 Upper border of liver dullness in right 5th intercostal space in mid-
clavicular line
 Shifting dullness & fluid thrill- absent

Digital Rectal Examination (DRE):- Not done
Mr. X, 60 years old smoker, non diabetic, normotensive farmer, hailing from South Surma, Sylhet
admitted to this hospital with the complaints of recurrent pain in the epigastric region. Initially
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pain was gradual in onset, mild to moderate in severity, burning in nature, radiates to back.
Pain usually occurs in empty stomach and he experiences pain at night which awakens him
from sleep. The pain is relieved from taking food & some other medicines. Pain occurs in
episode of every 3-4 months & persists for 2-3 weeks & resolves after treatment.
For last 1 year, the pain has increased in frequency & severity, becomes spasmodic in
nature, occurs after taking meal with a sensation of upper abdominal fullness & is relieved
after induced vomiting. For the last 1 year, he has also developed vomiting after taking
food. Vomiting is preceded by nausea, projectile in nature, foul smelling, profuse in
amount, containing undigested food materials, sour in taste, colorless, not mixed with
blood & not bile stained. He experiences a rolling mass in the upper abdomen for last 1
year, that appears usually after taking meal. His appetite is good, but for last 1 year,
because of pain after taking meal, he is afraid of taking food.
He has no history of vomiting of blood, passage of black tarry stool, yellowish discoloration
of eye. He is constipated & his bladder habit is normal
He has no history of cough, coughing up of blood, chest pain, breathlessness, bone pain or
back pain.
On general examination, he is non-anaemic, non-icteric, non cyanosed, dehydrated…....
Pulse is ___ beats/min, Blood pressure is ___ mmHg, Temperature is ___⁰C, Respiratory
rate is ___ breaths/min.
On local examination of abdomen & genitourinary system, abdomen is scaphoid in shape,
moves with respiration, umbilicus is centrally placed & inverted. There is mild epigastric
distension and there is visible peristalsis from left to right. There is no tenderness, muscle
guard or rigidity & succession splash is present. Hernial orifices are intact. No organomegaly
is present.
 Provisional diagnosis:- “Gastric Outlet Obstruction due to Pyloric stenosis due to

chronic duodenal ulcer”

 Carcinoma Stomach I. History of vomiting I. Long history
after taking meal II. Appetite is normal
III. Supraclavicular
lymph node not
enlarged
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IV. No palpable mass
V. There is no ascites,
and no feature of
distant metastasis
 Chronic pancreatitis I. Epigastric pain radiating to i. Visible peristalsis

back ii. Induced vomiting
iii. Pain not relieved by
Mohammadian
position
 Investigation:-
 For Diagnosis:-
1. Upper GI Endoscopy with biopsy
2. Barium meal X-ray of stomach & duodenum

v. Urine RME
vi. Chest X-ray
vii. ECG
 Confirmatory Diagnosis:- Gastric Outlet Obstruction due to Pyloric stenosis due to

chronic duodenal ulcer
 Treatment:-
Bilateral Truncal Vagotomy & Gastrojejunostomy Under G/A
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OBSTRUCTIVE JAUNDICE

Name:- Mr. X
Age:- 40 years
Sex:- Male
Religion:- Muslim
Occupation:- Farmer
1. Pain in right upper abdomen for 3 months

2. Yellow coloration of eyes, urine and skin for 2 months.
3. Fever with chills & rigor for 15 days.

According to the statement of patient, he was reasonably well 3 months back then he suddenly
experienced recurrent attacks of pain in right upper abdomen which was insidious in onset,
colicky in nature, radiated to whole upper abdomen and to back. Pain was aggravated by taking
meal and relieved by medications. Pain was associated with nausea and occasional vomiting.
Vomiting was non projectile, greenish yellow in color, bitter in taste, scanty in amount, not
blood stained and does not cause relief of her pain. She also complains of yellowish
discoloration of eye, urine & whole body 2 months back. This discolouration was gradually
deepening for 15 days but after that there was diminution of discolouration for about one
month. But for last 15 days, yellowish discoloration is again increasing in intensity. He stated of
two episodes of high grade fever with chill and rigors with increased discolouration of eyes and
urine one about 4 months back and another episode 2 months back. These episodes last for 5-6
days for which he was admitted into hospital and treated conservatively with intravenous
medications. He also complaints of generalized Itching which gets more worsened in evening
and night time which disturbs his sleep and more in flanks and thighs. He has good appetite &
His bowel habit is normal apart from passing pale stool for last 10 days and bladder habit is also
normal.
He is not a drug abuser and gave no history of prodromal symptoms or any travel history. He
gave no history of repeated blood transfusion, blood coming out in vomitus, altered coloured
21 | ©JRRMC-22©
stool,. He gave no history of chest pain, coughing out of blood, breathlessness bone pain or or
back pain. (to exclude Ca-head of the pancreas)
 History of Past illness:- He has no history of Diabetes mellitus, hypertension, bronchial

Asthma
 Past medical History:- He has no history of previous surgery or wasn’t hospitalized for any
illness.
 Drug history:- He took some medicines but, he could not mention the name of the drugs
 Family history:- None of his family members experienced similar disease & all are alive &
healthy
 Personal history:- He is smoker, took 15 sticks per day , but doesn’t drink alcohol
 Socio-economic history:- Low socio-economic status. He uses sanitary latrine & drinks tube-
well water.
 Immunization history:- He is immunized according to EPI schedule
 Allergic history:- No history of allergy to any drugs or medicine
Appearance:-
Body built:-
Co-operation:-
Decubitus:-
Anaemia:-
Jaundice:-
Cyanosis:-
Oedema:-
Dehydration:-
Clubbing:-
Koilonychia:-
Leuconychia:-
Pulse:-
Blood pressure:-
Respiratory rate:-
Temperature:-
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Lymph node:-
Thyroid gland:-

Inspection:-
1. Abdomen is normal in shape
3. Umbilicus centrally placed & inverted
4. Flanks are not full
5. Hair distribution normal
6. There are multiple scratch marks on different parts of the body
7. No visible scar mark or engorged superficial vein.
8. No visible peristalsis or visible pulsation
Palpation:-
 No tenderness, muscle guard or rigidity
 No palpable mass
 Gall bladder not palpable
 Murphy’s sign is negative
 Liver, spleen, kidneys are not palpable
Percussion:-
 Tympanitic all over the abdomen
 Upper border of liver dullness in right 5th intercostal space in mid-
clavicular line
 Shifting dullness & fluid thrill- absent

Digital Rectal Examination (DRE):- Not done
Mr. X, 40 years old smoker, non diabetic, normotensive farmer, hailing from South Surma,
Sylhet admitted to this hospital with the complaints of he recurrent attacks of pain in right
hypochondrium which was insidious in onset, colicky in nature, radiated to whole upper
23 | ©JRRMC-22©
abdomen and to back. Pain was aggravated by taking meal and relieved by medications. Pain
was associated with nausea and occasional vomiting. Vomiting was non projectile, greenish
yellow in color, bitter in taste, scanty in amount, not blood stained and does not cause relief of
her pain. She also complains of yellowish discoloration of eye, urine & whole body 2 months
back. Which was fluctuating in nature. He stated of two episodes of high grade fever with chill
and rigors with increased discolouration of eyes and urine one about 4 months back and
another episode 2 months back. These episodes last for 5-6 days for which he was admitted
into hospital and treated conservatively with intravenous medications. He also complaints of
generalized Itching which gets more worsened in evening and night time which disturbs his
sleep and more in flanks and thighs. He has good appetite & His bowel habit is normal apart
from passing pale stool for last 10 days and bladder habit is also normal.
He is not a drug abuser and gave no history of prodromal symptoms or any travel history. He
gave no history of repeated blood transfusion, blood coming out in vomitus, altered coloured
stool,. He gave no history of chest pain, coughing out of blood, breathlessness bone pain or or
back pain. (to exclude Ca-head of the pancreas)
On general examination, he is anxious, non-anaemic, icteric, non cyanosed, dehydrated,

accessible lymph nodes, especially left supraclavicular lymph node is not palpable….
Pulse is ___ beats/min, Blood pressure is ___ mmHg, Temperature is ___⁰C, Respiratory rate is
___ breaths/min. There are multiple scratch marks over different parts of the body.
On local examination of abdomen, abdomen is normal in shape, moves with respiration,
umbilicus is centrally placed & inverted. There is no tenderness, muscle guard or rigidity & no
visible peristalsis or pulsation. Gall bladder is not palpable & Murphy’s sign is negative. Hernial
orifices are intact. No organomegaly is present.
 Provisional diagnosis:- Obstructive jaundice due to stone in common bile duct


 Carcinoma head of the I. Jaundice present I. Painful jaundice
pancreas II. High coloured urine II. Fluctuating jaundice
& pale stool III. Fever will chills &
III. Generalized itching rigor is present
IV. Gall bladder is not
palpable
V. No history of loss of
appetite, weight loss
& other features of
distant metastasis
24 | ©JRRMC-22©
 Periampullary carcinoma I. Jaundice present I. Painful jaundice
II. High coloured urine II. Fluctuating jaundice
& pale stool III. Fever will chills &
III. Generalized itching rigor is present
IV. Gall bladder is not
palpable
V. No history of loss of
appetite, weight loss
& other features of
distant metastasis
 Investigation:-
 For Diagnosis:-
1. Ultrasonography of whole abdomen with special to Hepatobiliary
system & pancreas
2. Liver function tests:-
- Serum bilirubin
- ALP
- SGPT
- Serum albumin
- Prothrombin time
-
v. Urine RME
vi. Chest X-ray
vii. ECG
 Confirmatory Diagnosis:- Obstructive jaundice due to stone in common bile duct
 Treatment:-
Cholecystectomy with choledocholithotomy with T-tube drainage.
25 | ©JRRMC-22©

LONG CASE SURGERY Rafid Vai

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LONG CASE

JALALABAD RAGIB- RABEYA MEDICAL COLLEGE

Topic Page number

Chronic cholecystitis 2-6

Obstructive Jaundice 21-25

 Particulars of the Patient:-

 History of present illness:-

 History of Past illness:- Is there any H/O DM, HTN, TB

 Local Examination of Abdomen:-

Percussion:- Percussion note is Tympanitic

 Respiratory system:- Reveals no abnormalities.

 Provisional diagnosis:- Chronic calculous cholecystitis

Disease Points in favour Points in against

 For General Anaesthesia fitness:-

 Confirmatory Diagnosis:- Chronic Calculous Cholecystitis

 Treatment:- Laparoscopic Cholecystectomy under General Anaethesia

 Particulars of the Patient:-

 History of present illness:-

 Local Examination of Abdomen & Genitourinary system:-

Percussion:- Percussion note is Tympanitic

Disease Points in favour Points in against

 For General Anaesthesia fitness:-

 Confirmatory Diagnosis:- Right sided renal stone

 Particulars of the Patient:-

 History of present illness:-

 Local Examination of Abdomen & Genitourinary system:-

Percussion:- Percussion note is Tympanitic

 Respiratory system:- Reveals no abnormalities.

On general examination, he is non-anaemic, non-icteric, non cyanosed…....

Other system reveals no abnormalities.

 Provisional diagnosis:- Acute retention of urine due to benign enlargement of

Disease Points in favour Points in against

 Stricture urethra I. Poor stream i. No H/O hesitancy

 For General Anaesthesia fitness:-

 Confirmatory Diagnosis:- Acute retention of urine due to Benign enlargement of

 Particulars of the Patient:-

 History of present illness:-

 History of Past illness:- He has no history of Diabetes mellitus, hypertension, bronchial

 Local Examination of Abdomen:-

Auscultation:- Bowel sound is present.

 Provisional diagnosis:- “Gastric Outlet Obstruction due to Pyloric stenosis due to

Disease Points in favour Points in against

 Chronic pancreatitis I. Epigastric pain radiating to i. Visible peristalsis

 For General Anaesthesia fitness:-

 Confirmatory Diagnosis:- Gastric Outlet Obstruction due to Pyloric stenosis due to

Bilateral Truncal Vagotomy & Gastrojejunostomy Under G/A

 Particulars of the Patient:-

1. Pain in right upper abdomen for 3 months

 History of present illness:-

 History of Past illness:- He has no history of Diabetes mellitus, hypertension, bronchial

 Local Examination of Abdomen:-

Auscultation:- Bowel sound is present.

On general examination, he is anxious, non-anaemic, icteric, non cyanosed, dehydrated,

 Provisional diagnosis:- Obstructive jaundice due to stone in common bile duct

Disease Points in favour Points in against

 Confirmatory Diagnosis:- Obstructive jaundice due to stone in common bile duct

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