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 pains intensity didnt
  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 37C.
• 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
• Virchows 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
  Traubes 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 1100am
• BP 160/100 mmHg, Pulse 60bpm, Temperature37C
• 1)Colonoscopy done Transverse colon polyp found
  and removed

24
Final Diagnosis

• Transverse Colon Polyp.