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Juan Agustin D. Corua IV 2009A March 6, 2007

P-D II Medicine

Identifying Data

The patient is G.W., an 84 year-old married, Filipino, Catholic from Nueva Ecija, admitted for the 4 th time

at the UERMMMC last Feb. 20, 2007.

Chief Complaint: Abdominal pain for 1 month

Source and Reliability: Patient and daughter-in-law, good

Patient Profile

The patient lives with her husband, son and daughter-in-law. She starts her day at 4:00 AM. Upon

waking, she does household chores and eats breakfast. She then rests from 9:00 AM to 2:00 PM. Lunch

follows which usually consists of fish and vegetables. She would again attend to household chores. After

watching television, she retires at 10:00 PM. She has no vice.

History of Present Illness

The patient was well until six weeks PTA, when she experienced pain at the epigastric area. It would

radiate to the back and to the RLQ. She would double up due to the pain and would be relieved bydrinking milk or defecation. The onset of pain varies from time to time and would awaken her at night on

occasion. She also observed an urge to defecate when she is flatulent. Stool was described to be mucoid,

multiple, and round per episode.

Four weeks PTA, symptoms experienced since the onset persisted. She would notice blood streaks upon

wiping her anus and felt soft cushions protruding after defecation. Symptoms were also associated with

intermittent fever with the highest recorded temperature of 40 C per axilla which was relieved by taking

Paracetamol. She then decided to seek consult in a nearby hospital. She was given unrecalled medicationsin the hospital to alleviate her symptoms. She had CT-Scan and was diagnosed to have intestinal

Carcinoma. She was also given Omeprazole to relieve her condition.

Three weeks PTA, similar pain was experienced again. The patient also was worried about the diagnosis

given to her at the local hospital and prompted her to seek a 2 nd opinion at the UERMMMC OPD on the

day of admission.

Past Medical History

She underwent mastectomy on both breasts in 1975. She was diagnosed to have DM 15 yrs ago. She alsounderwent cholecystectomy 4 years ago.

Family History: Unremarkable

.

Physical Exam

General Survey: conscious, coherent. not in respiratory distress

Vital Signs: BP-110/80 mmHG RR-16/minute HR-60/minute PR-66/minute Temp-36.8 C

Skin: numerous gross lesions in the upper extremities and abdominal area, no jaundice

HEENT: normocephalic, anicteric sclerae, pink conjunctivae, OD-negative ROR with light

perception, OS-positive ROR, pupils equally reactive, intact direct and consensual reflex

bilateral, no nasal discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathy

Chest and Lungs: gross keloid over mammary area, absent breasts, equal chest expansion, equal

tactile fremitus, clear breath soundsCardiovascular: adynamic precordium, no palpable thrill, weak heart sounds, PMI located in 5 th

ICS, normal rate, normal sounds.

Abdomen: flabby abdomen, surgical scar on RUQ, 0.5cm nodule at RUQ, 0.3cm papule LLQ,

0.3 patch distributed in all quadrants, hyperactive bowel sounds, soft, no palpable masses, painupon deep palpation in RUQ, liver span is 8 cm.

Extremities: no cyanosis, no edema