CASE PRESENTATION

Ramirez, Jerusha Frances

Sonaimuthu, Prasanth
Tenedero, Adrian
Tibuc, Harriette Quimby
GENERAL DATA

Mr. L.C., 64 years old, male, married, Filipino, Roman Catholic,

elementary graduate, works as a tricycle driver, born on March 15
,1955 and presently residing in Luna, Isabela was admitted for the
second time last September 08, 2019 around 11 o’clock in the
morning at Cagayan Valley Medical Center.
CHIEF COMPLAINT

“Nagtae ako ng dugo” as verbalized by the patient

HISTORY OF PRESENT ILNESS

Six months prior to admission, the patient noticed an abdominal mass along his
umbilical area. He described it as non movable and non tender (size can not estimate).
No consult was done thereafter. Interval history reaveled that patient did not experience
any signs and symptoms of any illness. He does his daily activities without any physical
or health limitations.

Three days pior to admission, the patient experienced sudden umbilical to hypogastric
abdominal pain of burning sensation, rated as 5/10, non radiating while driving his
tricycle in the morning. Abdominal mass stated above was still observed. Upon arriving
at home, he suddenly felt the urge to defecate. Instead of stool, he passed fresh blood
(hematochezia) which he described as bright red approximately 500 mL. He took
amoxicillin thereafter. No consultation was done.
Two days prior to admission, abdominal pain of burning sensation with same
severity was still felt on the same area. The pain occured intermittently with no
aggravating factors. No hematochezia observed. He took the same medication and
still no consult was done.

One day prior to admission, abdominal pain of burning sensation was still
persistent, rated as 7/10 from his umbilical to hypogastric area. Hematochezia was
again experienced, about 500 mL. This prompted him to consult to CVMC for further
evaluation and management.
PAST MEDICAL HISTORY

Immunizations: Complete

Allergies: None

Current Medication: Amlodipine (5mg)

Losartan(50mg)

Childhood Illnesses: Measles, Chicken Pox, Mumps

Adult Illnesses: Hypertension (2012)

Surgical and previous Lipomectomy (2012)

hospitalization Appendectomy (1986)

Psychiatric: None
FAMILY HISTORY

His parents both died due to old age. There are 7 children in the family,the patient
is the eldest. Reports that all siblings are well and healthy except his younger sister
who also have hypertension.

No known history of cardiovascular, gastointestinal, pulmonary, endocrine, and

neurologic diseases.
PERSONAL AND SOCIAL HISTORY

The patient was born and raised in Luna, Isabela. He finished elementary education.
He's married for 35 years and has 3 children. At a young age, he worked as a
tricycle driver. He usually sleeps at 9 pm and wakes up at 5 am. His diet consists of
meat and vegetables. He is a non smoker and drinks alcohol occassionaly.
REVIEW OF SYSTEMS

Constitutional Weight loss, did not experienced fever and chills during the
course of illness.
SKIN No rashes, lumps, sores, itching, dryness, color change;
changesin hair or nails; changes in size or color of moles
HEAD Experienced dizziness; No headache, head injury,
lightheadedness.No history of head trauma/injury, and no
lightheadedness.
EYES Normal vision, does not use glasses or contact lensesno pain,
redness, excessive tearing, double or blurred vision, spots,
specks, flashing lights, glaucoma, cataracts
EARS No hearing problem, no earache, no tinnitus, no vertigo, no
infection, no discharge.
NOSE No nasal stuffiness. No epistaxis and no discharge.
THROAT/MOUTH Does not use dentures. No bleeding gums, no sore throat, no
dysphagia, no toothache, and no hoarseness.
NECK No lumps, no stiffness, no pain, and no swollen glands.
BREASTS No lumps, no pain, and no discharge.
RESPIRATORY No cough, no blood streaks and no difficulty of breathing.
CARDIOVASCULAR No Chest pain ,palpitations and easy fatigability
GASTROINTESTINAL (+)Porridge-like stool, No vomiting
URINARY No burning or pain on urination, no hematuria, no urinary infections, no kidney
stones, and incontinence
GENITAL No hernia, no discharge or sores, pain or swelling.
PERIPHERAL VASCULAR No pain or cramping in the extremeties

MUSCOLOSKELETAL No muscle weakness

PSYCHIATRIC No history of depression or treatment for psychiatric disorders.

NEUROLOGIC No fainting and seizures during course of illness, and No motor or sensory
loss.
HEMATOLOGIC No easy bleeding, no bruising.
ENDOCRINE Experienced heat intolerance and excessive sweating
PHYSICAL EXAMINATION

GENERAL SURVEY
The patient is awake, conscious and
coherent, oriented to time, place and
person. He is in good mood, not in
distress. He is cooperative, pleasant,
and shows no signs of irritability or
agitation. Good personal hygiene has
been noted. He is catheterized with an
ongoing IVF (D5W) on his right arm.
VITAL SIGNS
Temperature- 36.3˚C
Respiratory rate- 19 cpm
Pulse rate- 60 bpm
Blood Pressure- 110/70 mmHg
Oxygen Saturation: 97%
SKIN
Skin is warm and dry. Nails pale , without clubbing or cyanosis.

HEENT
Head: Head is normocephalic, symmetrical with no tenderness, no mass.
Eye: Visual fields are normal. Pale palpebral conjunctiva. Pupils are equally round and
reactive to light and accommodations.
Ear: Symmetrical with no external swelling, no redness, no visible discharge, no
tenderness, no hearing impairment, no masses, and no lesions
Nose: Symmetrical, no sinus tenderness, no congestion, no exudates.
Throat: Oral mucosa pink; no buccal lesions, uvula is in the midline. Tonsils not
enlarged.

NECK
Neck supple, trachea midline, no palpable lymph nodes.
CHEST AND LUNGS
The chest is bilaterally symmetrical in shape. The patient does not exhibit labored breathing nor
the use of accessory muscles of breathing; there is symmetrical lung expansion,clear breath
sounds.

HEART
Adynamic precordium, no scars in the chest and no chest wall deformities; (-) jugular vein
distension, Normal heart rate with regular rhythm

ABDOMEN
Globular abdomen,no discoloration with surgical scars from previous appendectomy and
lipomectomy. (+) umbilical mass, nontender,18 cm x18 cm. Normoactive bowel sounds, no
tenderness

MUSCULOSKELETAL
No joint deformities. Good range of motion on both left and right hand, elbows, shoulders, knees
and ankles.
EXTREMITIES
Warm and without edema, no tenderness, no deformities

NEUROLOGIC
Speech is normal, knowledgeable with current events. Memory is intact. Responds
appropriately to questions and can follow commands. All cranial nerves are intact. Good
muscle bulk and tone. There is normal sensation on all extremities.

HEMATOLOGIC
No bruise nor massive bleeding.
ASSESSMENT

Partial Gut Obstruction