CPC CASE STUDY NO. 1

CASE57 year-old man with severe abdominal pain

History of Present IllnessTwo days PTA patient experienced severe

right lower quadrant abdominal pain. Since onset, the pain worsened, and the patient has noticed his abdomen becoming progressively bloated.

The pain is associated with nausea and vomiting and the patient has not been able to have a bowel movement.

History of Present Illness he reports having night sweats, low grade

fever, intermittent abdominal discomfort with constipation and loss 30-lb weight loss over the past 2- months.

Past Medical HistoryHe has no significant history.

Not taking any medications.

Not on any weight loss regimen.

Family History history of colon cancer, soft tissue

sarcoma, pancreatic cancer, chronic myeloid leukemia (CML), and prostate cancer.

Physical Examination patient is alert and oriented. temp = 98.8˚F -PR= 65 bpm -RR= 18 breaths/min- BP 104/ 67 mmHg localized tenderness to palpation in the RLQ

with palpable mass.

Physical ExaminationHe has a generalized abdominal distension

but no guarding, rebound or percussion tenderness.

rectal examination reveals brown stool that is guaiac positive.

the findings from the respiratory and neurologic portions of the PE are unremarkable.

Laboratories:

The results of electrolyte panel, liver function test, and renal function test are within normal.

Labs Result Normal values Outcome

Hemoglobin 9.4 g/dl ( 94 g/l) 13.6 – 17.5 g/dl decreased

hematocrit 30.8% (0.308) 39-49% decreased

WBC 6.2 x103/ ul 4.4-11x103 / ul normal

Lactate dehydrogenase

285 U/L 88-230 U/L increased

Occult blood positive

Diagnostic Procedures colonoscopoy

- Visualization of the mucosa of the entire colon and terminal ileum.

- The test is indicated after a positive test for fecal occult blood.

- A fiberoptic endoscopy study in which the lining of the large intestine is examined for changes of the mucosal surface and for bleeding sites or strictures.

Diagnostic Procedure Abdominal UTZ

- to locate, visualize and determine the size of the mass.

- to determine what organs are affected.- to assess needle biopsy for getting

specimen.

Diagnostic Procedure Needle Biopsy- to get a sample of cells or tissues for

examination.- for histologic confirmation

Admitting ImpressionIntestinal obstruction secondary to mass

Reference Current medical diagnosis and treatment,

2009 Harrison’s Principles of Internal Medicine,

17th Edition