History Of Present Illness Patient from Out Patient Department after seen by Doctor Koh Noha. He Escorted By Medical Assistance Officer and relative with stretcher. Patient alert and conscious. Patient infected by Tinea Corporis. Vital Sign taken:
- Blood Pressure : 141/90 mmHg - Pulse Rate : 64/min - Respiration Rate : 21/min - Temperature : 37 c - Dextrose Test : 6.4 mmol/L Past Medical / Surgical History Patient has history of allergies with seafood. No history of past medical history. No history of past surgical history. Family History No history of Diabetes Mellitus and Hypertension among family members. Sosial History Patient got married. Patient not smoking. Patient not alcohol drinker. Patient work as labour since age 17. Admission In Ward Umbilical pain 3 days ago. Sudden onset. High grade of pain. Limited movement and activity. Physical Examination Patient alert and conscious but in pain. Glassgow Coma Scale is 15/15 ( Eyes:4, Verbal:5, Motor: 6 ). Edema at both legs ( Crural ). Infected by Tinea Corporis. No respiratory distress. No pallor and cyanosis noted. No clubbing finger and jaundice. Vital Sign : - Blood Pressure : 141/90 mmHg - Pulse Rate : 64/min - Respiration Rate : 21/min - Temperature : 37 c - Dextrose Test : 6.4 mmol/L - Pulse Rhythm : Regular - Pain Score : 6/10 - SPO2 : 99%
Head Inspection : - No swelling or active bleeding. - Normal shape. - Redness of the skin.
Palpation: - No swelling. - No abnormalities.
Eyes Inspection : - No blurring of vision. - No discharge from both eyes. - No jaundice. Palpation : - No per orbital tenderness of swelling noted.
Ears Inspection : - No active bleeding or swelling. - Both ears remain in same size - No discharged at both ears noted. - No abnormalities of hearing. Palpation : - No tenderness. - No mass palpated. - No scars. Nose Inspection : - No bleeding and swelling. - No discharged found. Palpation : - No tenderness. - No mass found. Throat - No inflammation around the throat. - Dry lips. Mouth - Dry lips. Neck Inspection : - No dysphagia. - No swelling. Palpation : - No lymph node swelling. - No tenderness. - No mass palpated.
Respiratory System Inspection : - Shape and symmetrical of chest normal. - Anterior and posterior chest wall normal. - No coughing. - No Breathlessness. Palpation : - Chest expansion normal. - Apex beat normal. - No vocal fremitus. - Ribs no pain localized. Percussion : - Cardiac dullness normal. - Normal resonance at both lungs. Auscultation : - Breath sound no ronchi, no crepitation. - No added sound. - Inspiration and aspiration equal bilateral.
Cardiovascular System Inspection : - No previous operation scar on chest wall. - No abnormalities found. Palpation : - No chest pain or tenderness. - Apex beat at 5 th intercostals space mid clavicular line. Percussion - Normal cardiac dullness at the fifth intercostals space. Auscultation : - Dual rhythm no murmur. - Heart beat sound 1 and 2 clearly heard.
Abdomen Inspection : - No extending of scrotum. - Cough impulse cause pain at umbilical area. - Bulge at umbilical. - No surgical scar seen. Palpation : - Pain at umbilical area. Percussion: - Normal resonance. - No fluid thrill. Auscultation: - Bowel sound present in normal condition. - No bruit sound.
Genetalia : - No abnormalities. - No scrotal hydrocele found.
Central Nervous System Upper Extremities - No deformity or abnormalities found. - Able to move both hand without restriction. Lower Extremities - No deformity or abnormalities found. - No loss of sensation. - Pitting edema at crural. - Pain but able to move. - Capilary refill 2 second.
Management Pre Operation - Soft diet. - Take antibiotic medicine. - Shower the night before, using antibacterial soap. - The night before, eat a light meal. Do not eat or drink anything after midnight. - Wear comfortable clothing. Post Operation - return to normal diet after a few days. - During the first few days, slowly return to your normal routine. - Take pain medicine as needed. - Ask your doctor about when you can do certain activities (eg, driving, sexual activity). You may need to wait 1-2 weeks. - Avoid excess strain (eg, vigorous exercise and lifting) for 6-8 weeks. Investigation - Physical exam - Blood tests - Urine tests - Electrocardiogram (EKG, ECG)-a test that records the heart's activity by measuring electrical currents through the heart muscle. - Stop taking some medicines up to one week before the procedure : o Aspirin or other anti-inflammatory drugs o Blood thinners, such as clopidogrel (Plavix) or warfarin (Coumadin) -
Maintain a healthy weight. Strengthen your abdominal muscles. Treat chronic constipation , allergies , or chronic cough . Eat a high-fiberdiet .