OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: Cruz, Estrella Address: 623 Amarlanhagui St. Tondo, Manila Date of Admission: April 23, 2008 Admitting Diagnosis: Colonic cancer Residents-in-charge: Drs. Receno/Indon/Cruz Clerks in charge: Fabian/Item/Junsay
Hospital #: 1823989 Age/Sex: 57/F
CLINICAL ABSTRACT This is a case of a 57 year old female from Manila who came in due to on and off abdominal pain. History of Present Illness 4 months PTA, patient experienced epigastric pain, burning in character, 10/10. There was also associated loose bowel movement about 10x per day, on and off and loss of appetite. Consult done at PGH and medication taken was Simeco which provide temporary relief. 3 months PTA, condition persisted still with associated loose bowel movement about 4 times/day. Consult done at Mary Johnson Hospital. Fecalysis done, amebiasis. Medication taken were metronidazole and ciprofloxacin. There was no relief. 2 months PTA, follow-up done at Mary Johnston hospital due to persistence of condition. There was no fever. Medications taken were ofloxacin and metronidazole. 1 week PTA, patient had soft abdominal pain and LBM with noted loss of weight of about less than 50% in 4 mos. There was consult done at OMMC IM-OPD. No fever, no vomiting, no melena was observed. CT scan of the whole abdomen was done. Few hours PTA, patient had a follow-up at IM-OPD OMMC and noted of CT Scan results and was transferred at IM-ER OMMC and advised colonoscoscopy hence admission. Past Medical History (+) Hepatitis B infection (Feb 2008) No allergy No previous operation No DM, HTN, CAD, PTB Family History Denies Heredofamilial Disease Personal and Social History Non smoker. Alcoholic beverage non drinker. No history of illicit drug use. Review of Systems GENERAL: No weight loss, no fever, nor chills, no anorexia, (+) gen body weakness INTEGUMENT: Skin: no pruritus, no cyanosis, no pallor, no easy bruisability. Hair: no loss of hair and abnormal hair growth HEENT: Head: No headache, no dizziness Eyes: No pain, itchiness, double vision. No discharge. Ears: No earache, discharge, tinnitus. No difficulty of hearing. Nose: No nosebleeding, dryness, obstruction, nor nasal discharge; Mouth: No gumbleeding, inflammation of the tonsils, soreness, hoarseness, no dentures. RESPIRATORY: No hemoptysis, No dyspnea, no easy fatiguability CARDIAC: No chest pain, palpitation, no easy fatigability, No PND, No orthopnea GIT: No changes in bowel/ bowel movement, no history of constipation, no diarrhea. GENITOURINARY: No dysuria, hematuria, or nocturia, no oliguria HEMATOLOGIC: No bruise in non-traumatic areas. NEUROMUSCULAR and MUSCULOSKELETAL: No memory loss. No tremors, paresthesia, nervousness. ENDOCRINE: No cold/heat intolerance; no sluggishness. No polydipsia, plyuria, and polyphagia. Physical Examination: General: concious, coherent, not in cardiorespiratory distress Vital Signs: BP: 110/70 mmHg HR: 80 bpm RR: 17 cpm Temp: 37.1°C Skin: no jaundice, no pallor, no cyanosis HEENT:non- icteric sclerae, pink palpebral conjunctivae, no nasoaural discharge, no TPC, no CLAD,(-) neck vein engorgement CHEST and LUNGS: symmetrical chest expansion, no lagging, no retractions, clear breath sounds. HEART: adynamic precordium, PMI at 5th ICS LMCL, NRRR, no murmur ABDOMEN: globular, normoactive bowel sounds, soft, non-tender, (+) epigastric void mass, non tender, non pulsating EXTREMITIES: grossly normal, full and equal pulses, pale nail beds, no edema Assessment: Colonic CA Plan: for admission Input and output monitoring Soft diet Insert Heplock Labs:
FOBT CTScan CBC with PC BUN, Crea, Na, K Stool exam Urinalysis ECG CXR-PA CEA UTZ of whole abdomen Meds: o Ferrous Sulfate 1tab tid o Omeprazole 40mg OD o Metronidazole 500mg q8 hours o Cefuroxime 750mg q8 hours VSq 2 hours
Course in the wards: 24 On the first hospital day, patient’s diet was maintained as well as the heplock. Pending labs were carried out. CXR and 12 L ECG was requested. Official CT scan result was for follow-up. Medications were continued. Follow up referral to surgery. Patient was placed on moderate to high back rest. Input and output monitoring. Vital signs were monitored every 2 hours. 25 On the second hospital day, patient’s diet was maintained as well as the heplock. Patient was requested to be refered to Anesthsiology for IV sedation. Medications were continued. Patient was placed on moderate to high back rest. Input and output monitoring. Vital signs were monitored every 4 hours. Colonoscopy was scheduled for tomorrow. Bowel prep was done. 26 On the third hospital day, colonoscopy was scheduled today were continued. Patient was placed on moderate to high back rest. Input and output monitoring. Vital signs were monitored every 4 hours.