IMS: Case 2

1. IMS: Case 2

2. Personal Details Patient Name : BKB Registration No. : HTJ398311 Age : 63 Gender : Male Race : Malay Religion : Muslim Occupation : Retired Teacher Marital Status : Married with 4 children Date of Admission : 31/03/09 Date of Clerking : 01/04/09

3. Pain at the right & left lower abdomen for the past 1 month Chief Complaint

4. History of Presenting Illness • Intermittent, sharp, ‘stabbing’ pain of moderate intensity • shifts between his right lower abdomen and left lower abdomen • radiates to the back on the ipsilateral side • Not influenced by the intake of food, fasting, or time of day • For the past 1 month, the pain’s intensity didn’t change. • Not relieved by medication prescribed by clinic for gastritis • Positive associated symptoms • Patient complains of having intermittent episodes of constipation and diarrhoea since 1 month ago, with occasional black stools and tenesmus. • Patient has noticed some weight loss over the past few months – unable to specify how much. • Negative associated symptoms • no fever, no cold, no cough and no shortness of breath, no vomiting, no haematemesis, no heartburn symptoms, no chest pain, no loss of appetite.

5. Systemic Review • Gastrointestinal system : • intermittent constipation and diarrhoea since 1 month ago, with stools being occasionally black. no regurgitation, no vomiting, no haematemesis, no abdominal distention, and no colicky pain in the abdomen. • Respiratory system : • no shortness of breath, cough, haemoptysis, dyspnoea, paroxysmal nocturnal dysnoea, orthopnoea, or chest pain. • Cardiovascular system : • no palpitations, no chest pain, no dizziness, no noticeable change in the colour of hands and feet and no recollection of fainting.

6. Systemic Review • Urogenital system : • no change in urination habit. no symptoms of obstruction such as weak flow, hesitancy, terminal dribbling or incomplete evacuation. no symptoms of bladder irritation such as increase in urination frequency, urgency to urinate, nocturia or dysuria. And no polyuria or loin/groin pain. • Nervous system : • no headaches, no tremors and no changes in his sensations of smell, touch,vision or hearing. • muscle weakness and diminished motor response on his right upper and lower limb, but does not notice any change in sensations felt. • Musculoskeletal system : • no muscle aches or joint pains.

7. Past Medical History Hypertension diagnosed in 1989 and currently on Betaloc and Adalat for it Stroke(alleged left side of brain) in 1998 and was admitted to Hospital Tuanku Jaafar, after which he noticed muscle weakness and diminished motor response on his right upper and lower limb, no change in sensations felt. He has no history of diabetes or asthma. No allergies.

8. Family History No significant family history other than his mother(Hypertensive) who has passed away (unable to recall the cause of death)

9. Social History Mr. BKB does not smoke and does not consume alcoholic beverages.

10. Physical Examination • Conscious, alert, communicative, and responsive. • not in any obvious pain or respiratory distress. • Vital Signs • Pulse rate : 60 bpm • Blood pressure : 160/70 mmHg • Temperature : 37˚C. • Respiratory rate : 17 breaths per minute.

11. Physical Examination • Hands • Warm and moist. • There was a branula on the dorsal aspect of his right hand. • There was slight thenar and hypothenar wasting on his right hand. • no clubbing, no peripheral cyanosis, no palmar erythema, no leukonychia, no koilonychia, no fine or flapping tremor • Capillary refill was less than 2 seconds. • Arms • His radial pulse was 60 beats per minute, regular in rhythm, of strong volume, and there was no radial-radial delay. • Skin turgor was normal • no bruises, petechia, or scratch marks on the arms.

12. Physical Examination • Eyes • no pallor, jaundice, corneal archus or xanthelesma • Mouth • decent oral hygiene with good hydration. • no fetor hepaticus, no central cyanosis, no frenulum jaundice, no angular stomatitis, no leucoplakia, no glossitis, and no high-arched palate. • Neck • There were no swellings, discharge, discolouration or lymphadenopathy around the neck • Virchow’s node was not palpable • Jugular Venous Pressure was 3 cmH2O.

13. Chest examination Cardiovascular System • Inspection: • the size and shape is normal. no spider naevi, and no loss of axillary hair. • Palpation • The apex beat was palpable at the 5th intercostals space, approximately 1cm lateral to the mid-clavicular line. • no palpable thrills or parasternal heave. • Auscultation • the first and second heart sounds were heard, There were no added heart sounds and no murmurs. 

14. Chest examination Respiratory • Inspection: • Chest moves in and out with respiration • Palpation: • no tracheal deviation, tracheal tug or tracheal descent. • Chest expansion was present and equal on both sides. • Tactile fremitus was present and equal on both sides. • Percussion: • both sides were equally resonant. • Auscultation: • vesicular breath sounds were heard on both sides; no bronchial breath sounds, no crepitations and no pleural-rubs. • There was equal vocal resonance on both sides.

15. Abdominal Examination Abdomen • Inspection: • the shape was slightly concave, with no sign of distention. Umbilicus is inverted. No dilated veins, no obvious swellings, no obvious peristalsis and no striae • Palpation: • On light palpation: no tenderness, no superficial mass and no guarding. • On deep palpation: no masses were felt, no guarding and no tenderness. • Auscultation: • bowel sounds were increased in frequency. No bruits were heard. • Liver was not palpable under the costal margin and its span is approximately 9cm. • Spleen was not palpable under the costal margin and there was resonance on percussion of Traube’s space. • His kidneys were not ballotable and renal punch was negative on both sides.

16. Per Rectal Examination His prostate gland was not enlarged and there were no palpable masses. There was no rectal bleeding and no malaena.

17. Lower Limbs equal, normal temperature on both sides, no tenderness and no ulcers. There was no pedal edema; Dorsalis pedis and Posterior Tibial pulses were palpable, regular in rhythm, of strong volume and symmetrical on both sides.

18. CNS examination There was no tenderness of the joints or muscles. There was slight muscle wasting of his right upper and lower limb. The joints had normal range of movement. Muscle tone and power were were diminished on his right upper and lower limb. He exhibited an apraxic gait on his right side.Coordination and reflexes were present and normal. The patient responded to light touch and pain. Proprioception was intact. Mr. BKB registered at E-4 V-5 M-6, hence 15/15 on the Glasgow Coma Scale.

19. Provisional Diagnosis: Colorectal Carcinoma • Differential Diagnosis: • Inflammatory Bowel Disease • Diverticulitis

20. Investigations • 1)ECG: No ischaemic changes • 2)Colonoscopy done: 1/4/09 • Rectum-No Abnormalities Detected • Sigmoid Colon-No Abnormalities Detected • Descending Colon-No Abnormalities Detected • Transverse Colon-Polyp detected and removed. • Ascending Colon-No Abnormalities Detected

21. Investigations

22. Investigations

23. Management • 1/4/09; 11:00am • BP: 160/100 mmHg, Pulse: 60bpm, Temperature:37˚C • 1)Colonoscopy done: Transverse colon polyp found and removed

24. Final Diagnosis • Transverse Colon Polyp.