Group B
Sub block 1
Capuyan, Candelaria, Cariaso, Carlos, Castilllo, Clavillas
HISTORY
OF PRESENT ILLNESS
Identifying Data
G.S.M.
45 years old Filipino
Male Roman Catholic
Date of Birth: Date of Admission: May
12/21/1971 11, 2017
Romblon Date of Interview: May
11, 2017
Blood-tinged stool
CHIEF COMPLAINT
8 months PTA
Blood-tinged stool
Two episodes, watery
Abdominal pain
Cramping, 3/10
Diffused, no radiation
Relieved by HNBB
(-) Vomiting, fever
No consultation was done
7-4 months PTA
Blood-tinged stool
Occasional, watery
Abdominal pain
Recurrent, crampy, no radiation
Diffused, left quadrant
3-5/10
Relieved by HNBB
Weight loss
Gradual
Approximately 58 kg-54 kg
Loss of appetite
7-4 months PTA
(-) Fever, vomiting
No consultation was done
3 months -1 month PTA
Bloody stool
Watery
Recurring
Associated with occasional bowel incontinence
Abdominal pain
Diffused-left quadrant, no radiation
5-7/10
Partially relieved by HNBB
Weight loss
54 kg 49 kg
Associated with loss of appetite and fatigue
3 months -1 month PTA
(-) fever, vomiting
No consultation was done
1 Week PTA
Bloody stool
Watery
Recurring
(+) bowel incontinence
Abdominal pain
Diffused-left quadrant, no radiation
7/10
Associated with abdominal distention
Not relieved relieved by HNBB
(+) weight loss, fatigue, loss of appetite
(-) vomiting, fever
Consultation done
1 week pta
COLONOSCOPY 5/5/17 (FINDINGS):
Sigmoid mass most likely malignant s/p biopsy
Internal hemorrhoids
1 week pta
MULTI SLICE CT-SCAN 5/8/17 (IMPRESSION):
Heterogeneously enhancing mass in the sigmoid colon
Colovesical fistula
Urinary bladder wall thickening
Ascending colon diverticula w/o signs of inflammation
Small to marginal sized mesenteric lymph nodes
Subcentimeter hepatic microdensities
Gallbladder microlithiasis
Non-specific left renal cortical hypodensity
Decreased right nephrogram enhancement
Degenerative osseous changes
Consider bilateral sacro-iliitis
PAST MEDICAL HISTORY
Past Medical History
No previous admissions
No previous surgeries
No history of blood transfusion
No allergies to any medication and food
No chronic NSAID use
(-) Diabetes, Tuberculosis, Thyroid disease,
Cardiovascular disease, Hypertension
(+) Psoriasis
(+) Recurrent UTI
FAMILY HISTORY
Family History
(+) Hypertension mother
(+) Hypertension father
(-) History of cancer
Personal and Social History
Personal and Social
History
(+) Smoker
15 pack years
(+) Alcoholic drinker
12 bottles of beer/gin per week
Stopped 4 years ago
(-) illicit drug use
Review of Systems
REVIEW OF SYSTEMS
Gener (-) Febrile episodes
al
(-) Skin discoloration
Skin (-) Dryness, itchiness, rashes,
sores, lumps; Hair changes
(-) Headache, dizziness,
Head lightheadedness
(-) Blurred of vision; (-) pain, redness,
Eyes excessive tearing, spots, specks,
flashing lights.
(-) Tinnitus; (-) vertigo, earaches,
Ears infection, discharge
Nose
and (-) Colds, nosebleeds; sinus trouble
Sinuses
Throat
(-) Bleeding, (-) dentures, (-) sore
(Mouth
tongue, (-) dry mouth, (-) sore
and throat, (-) hoarseness, (-) thrush, (-)
Pharyn non-healing sores
x)
(-) Swollen glands, lumps,
Neck
pain, or stiffness in the neck
(-) Cough, difficulty of
Respirat
ory breathing, shortness of breath,
audible wheezing
(-) Easy fatigability,
Palpitations
CVS
(-) Orthopnea, Paroxysmal
Nocturnal Dyspnea
(-) Heartburn, Nausea and vomiting,
GIT Constipation, Steatorrhea
(+) Burning or pain during urination
Urinary (-) Suprapubic pain, incontinence
Periphe
ral (-) Edema; (-) color change in fingertips or
Vascula toes
r
(-) Muscle and joint pain; (-) Paralysis,
numbness or loss of sensation (-) tingling or
NMS pins and needles, tremors or other
involuntary movements; (-) seizures
(-) Heat or cold intolerance,
Endocri excessive sweating, excessive
ne thirst or hunger, polyuria,
change in glove or shoe size
PHYSICAL EXAMINATION
GENERAL APPERANCE
Awake, conscious, coherent
Not in cardiorespiratory distress
VITAL SIGNS
Blood Pressure:
100/70 Pain Scale: 4/10
Heart Rate: 92
Height: 55
bpm
Respiratory Rate: Weight: 49 Kg
24
BMI: 17.9
Temperature: 36.0 (underweight)
Degree Celsius
O2 Saturation: 98%
Pale skin
Warm, dry, elastic and mobile
No primary and/or secondary lesions
SKIN noted
No cyanosis, erythema , angiomatas
noted
No Jaundice
HEAD No tenderness, lesion noted on
AND scalp
FACE
No esotropia, exotropia, exophthalmia
Pupil are equal and reactive to light and
accommodation
EYES Pale palpebral and bulbar conjunctiva
Anicteric Sclerae
Lacrimal apparatus is moist
Some cerumen noted on
external ear
Responds to normal and
whispered voice on both ears
EARS Air conduction is longer than
bone conduction on Rinnes
test
Equally lateralize on both ear
on Webers test
Septum in the midline
NOS Both nostrils are patent.
E Nasal sinus non tender
no cyanosis, dryness, lesions
MOUTH
noted
Uvula is at the midline.
PHARYNX Tonsils not inflamed
Positive gag reflex
No atrophy noted
No palpable cervical
NECK lymphadenopathy
No neck vein distention
Thyroid gland non palpable
Adynamic precordium
No heaves, lifts, thrills
Point of maximal impulse palpated at 5th
HEART intercostal space left mid clavicular line
Apex Beat same as PMI
No murmur
No pectus excavatum nor carinatum
Equal chest expansion
With regular breathing pattern
Equal tactile fremitus
Resonant
LUNGS Vesicular breath sound
No adventitious breath sound
No egophony or whispered pectoriloquy
ABDOMEN
Soft, globular abdomen
Normoactive bowel sound
Tender on deep palpation on left lower
quadrant
No palpable mass
Liver and spleen is non-palpable
Abdomen
(-) Murphys Sign
Negative Cullens and Grey Turners Sign
No Psoas, Obturator, Rovsings Sign
No fluid shift
No CVA tenderness
DRE: No mass, non-tender, non-collapsed
rectal vault, good sphincteric tone, no blood,
no fecal material
Bladder non palpable
GUT No genital lesions, discharges noted
Full equal pulses
No palpable lymph nodes, no edema
PERIPHERAL noted
No nailbed cyanosis, no clubbing
Capillary refill less than 2 seconds.
No lesions, deformity noted
Symmetrical range of motion without any
MUSCULOSKELETAL difficulty
Normal muscle tone. Grade 5/5 muscle
strength
SALIENT FEATURES
HISTORY
PHYSICAL EXAM
