IMS: Case 2IMS: Case 2

Personal DetailsPersonal Details

Patient Name Patient Name : : BKBBKBRegistration No. Registration No. : : HTJ398311HTJ398311Age Age : : 6363Gender Gender : : MaleMaleRace Race :: Malay MalayReligion Religion :: Muslim MuslimOccupation Occupation :: Retired Teacher Retired TeacherMarital Status Marital Status :: Married with 4 Married with 4

childrenchildrenDate of AdmissionDate of Admission : : 31/03/0931/03/09Date of Clerking Date of Clerking : : 01/04/0901/04/09

Pain at the right & left Pain at the right & left lower abdomen for the lower abdomen for the

past 1 monthpast 1 month

Chief ComplaintChief Complaint

History of Presenting IllnessHistory of Presenting Illness Intermittent, sharp, ‘stabbing’ pain of moderate intensityIntermittent, sharp, ‘stabbing’ pain of moderate intensity shifts between his right lower abdomen and left lower shifts between his right lower abdomen and left lower

abdomenabdomen radiates to the back on the ipsilateral sideradiates to the back on the ipsilateral side Not influenced by the intake of food, fasting, or time of dayNot influenced by the intake of food, fasting, or time of day For the past 1 month, the pain’s intensity didn’t change.For the past 1 month, the pain’s intensity didn’t change. Not relieved by medication prescribed by clinic for gastritis Not relieved by medication prescribed by clinic for gastritis Positive associated symptomsPositive associated symptoms

Patient complains of having intermittent episodes of Patient complains of having intermittent episodes of constipation and diarrhoea since 1 month ago, with occasional constipation and diarrhoea since 1 month ago, with occasional black stools and tenesmus.black stools and tenesmus.

Patient has noticed some weight loss over the past few months Patient has noticed some weight loss over the past few months – unable to specify how much.– unable to specify how much.

Negative associated symptomsNegative associated symptoms no fever, no cold, no cough and no shortness of breath, no no fever, no cold, no cough and no shortness of breath, no

vomiting, no haematemesis, no heartburn symptoms, no chest vomiting, no haematemesis, no heartburn symptoms, no chest pain, no loss of appetite.pain, no loss of appetite.

Systemic ReviewSystemic Review

Gastrointestinal system : Gastrointestinal system : intermittent constipation and diarrhoea since 1 month intermittent constipation and diarrhoea since 1 month

ago, with stools being occasionally black. no ago, with stools being occasionally black. no regurgitation, no vomiting, no haematemesis, no regurgitation, no vomiting, no haematemesis, no abdominal distention, and no colicky pain in the abdominal distention, and no colicky pain in the abdomen.abdomen.

Respiratory system : Respiratory system : no shortness of breath, cough, haemoptysis, dyspnoea, no shortness of breath, cough, haemoptysis, dyspnoea,

paroxysmal nocturnal dysnoea, orthopnoea, or chest paroxysmal nocturnal dysnoea, orthopnoea, or chest pain. pain.

Cardiovascular system : Cardiovascular system : no palpitations, no chest pain, no dizziness, no no palpitations, no chest pain, no dizziness, no

noticeable change in the colour of hands and feet and no noticeable change in the colour of hands and feet and no recollection of fainting.recollection of fainting.

Urogenital system : Urogenital system : no change in urination habit. no symptoms of obstruction no change in urination habit. no symptoms of obstruction

such as weak flow, hesitancy, terminal dribbling or such as weak flow, hesitancy, terminal dribbling or incomplete evacuation. no symptoms of bladder irritation incomplete evacuation. no symptoms of bladder irritation such as increase in urination frequency, urgency to such as increase in urination frequency, urgency to urinate, nocturia or dysuria. And no polyuria or loin/groin urinate, nocturia or dysuria. And no polyuria or loin/groin pain.pain.

Nervous system : Nervous system : no headaches, no tremors and no changes in his no headaches, no tremors and no changes in his

sensations of smell, touch,vision or hearing. sensations of smell, touch,vision or hearing. muscle weakness and diminished motor response on his muscle weakness and diminished motor response on his

right upper and lower limb, but does not notice any right upper and lower limb, but does not notice any change in sensations felt.change in sensations felt.

Musculoskeletal system : Musculoskeletal system : no muscle aches or joint pains. no muscle aches or joint pains.

Systemic ReviewSystemic Review

Past Medical HistoryPast Medical History

Hypertension diagnosed in 1989 and Hypertension diagnosed in 1989 and currently on Betaloc and Adalat for itcurrently on Betaloc and Adalat for it

Stroke(alleged left side of brain) in 1998 Stroke(alleged left side of brain) in 1998 and was admitted to Hospital Tuanku and was admitted to Hospital Tuanku Jaafar, after which he noticed muscle Jaafar, after which he noticed muscle weakness and diminished motor weakness and diminished motor response on his right upper and lower response on his right upper and lower limb, no change in sensations felt. limb, no change in sensations felt.

He has no history of diabetes or asthma.He has no history of diabetes or asthma.No allergies.No allergies.

Family HistoryFamily History

No significant family history other No significant family history other than his mother(Hypertensive) who than his mother(Hypertensive) who has passed away (unable to recall has passed away (unable to recall the cause of death)the cause of death)

Social HistorySocial History

Mr. BKB does not smoke and does Mr. BKB does not smoke and does not consume alcoholic beverages.not consume alcoholic beverages.

Physical ExaminationPhysical Examination

Conscious, alert, communicative, and Conscious, alert, communicative, and responsive. responsive.

not in any obvious pain or respiratory not in any obvious pain or respiratory distress. distress.

Vital SignsVital SignsPulse ratePulse rate : 60 bpm: 60 bpmBlood pressureBlood pressure : : 160/70 mmHg160/70 mmHgTemperatureTemperature : 37˚C. : 37˚C. Respiratory rate Respiratory rate : 17 breaths per : 17 breaths per

minute.minute.

Physical ExaminationPhysical Examination HandsHands

Warm and moist. Warm and moist. There was a branula on the dorsal aspect of his right There was a branula on the dorsal aspect of his right

hand.hand. There was slight thenar and hypothenar wasting on his There was slight thenar and hypothenar wasting on his

right hand.right hand. no clubbing, no clubbing, no peripheral cyanosisno peripheral cyanosis, no palmar , no palmar

erythema, no leukonychia, no koilonychia, no fine or erythema, no leukonychia, no koilonychia, no fine or flapping tremorflapping tremor

Capillary refill was less than 2 secondsCapillary refill was less than 2 seconds.. ArmsArms

His radial pulse was 60 beats per minute, regular in His radial pulse was 60 beats per minute, regular in rhythm, of strong volume, and there was no radial-radial rhythm, of strong volume, and there was no radial-radial delay.delay.

Skin turgor was normal Skin turgor was normal no bruises, petechia, or scratch marks on the arms.no bruises, petechia, or scratch marks on the arms.

Physical ExaminationPhysical Examination EyesEyes

no pallorno pallor, jaundice, corneal archus or xanthelesma, jaundice, corneal archus or xanthelesma MouthMouth

decent oral hygiene with good hydration. decent oral hygiene with good hydration. no fetor hepaticus, no central cyanosis, no no fetor hepaticus, no central cyanosis, no

frenulum jaundice, no angular stomatitis, no frenulum jaundice, no angular stomatitis, no leucoplakia, no glossitis, and no high-arched palate.leucoplakia, no glossitis, and no high-arched palate.

NeckNeck There were no swellings, discharge, discolouration There were no swellings, discharge, discolouration

or lymphadenopathy around the neck or lymphadenopathy around the neck Virchow’s node was not palpableVirchow’s node was not palpable Jugular Venous Pressure was 3 cmHJugular Venous Pressure was 3 cmH22O. O.

Chest examinationChest examination

Cardiovascular SystemCardiovascular System Inspection: Inspection:

the size and shape is normal. no spider naevi, and no the size and shape is normal. no spider naevi, and no loss of axillary hair. loss of axillary hair.

PalpationPalpation The apex beat was palpable at the 5The apex beat was palpable at the 5thth intercostals space, intercostals space,

approximately 1cm lateral to the mid-clavicular line. approximately 1cm lateral to the mid-clavicular line. no palpable thrills or parasternal heave. no palpable thrills or parasternal heave.

AuscultationAuscultation the first and second heart sounds were heard, There the first and second heart sounds were heard, There

were no added heart sounds and no murmurs. were no added heart sounds and no murmurs. 

Chest examinationChest examination

RespiratoryRespiratory Inspection: Inspection:

Chest moves in and out with respirationChest moves in and out with respiration Palpation:Palpation:

no tracheal deviation, tracheal tug or tracheal no tracheal deviation, tracheal tug or tracheal descent. descent.

Chest expansion was present and equal on both sides. Chest expansion was present and equal on both sides. Tactile fremitus was present and equal on both sides. Tactile fremitus was present and equal on both sides.

Percussion:Percussion: both sides were equally resonant. both sides were equally resonant.

Auscultation:Auscultation: vesicular breath sounds were heard on both sides; no vesicular breath sounds were heard on both sides; no

bronchial breath sounds, no crepitations and no bronchial breath sounds, no crepitations and no pleural-rubs. pleural-rubs.

There was equal vocal resonance on both sides. There was equal vocal resonance on both sides.

Abdominal ExaminationAbdominal Examination

AbdomenAbdomen Inspection:Inspection:

the shape was slightly concave, with no sign of distention. the shape was slightly concave, with no sign of distention. Umbilicus is inverted. No dilated veins, no obvious swellings, Umbilicus is inverted. No dilated veins, no obvious swellings, no obvious peristalsis and no striaeno obvious peristalsis and no striae

Palpation:Palpation: On light palpation: no tenderness, no superficial mass and no On light palpation: no tenderness, no superficial mass and no

guarding. guarding. On deep palpation: no masses were felt, no guarding and no On deep palpation: no masses were felt, no guarding and no

tenderness.tenderness. Auscultation: Auscultation:

bowel sounds were increased in frequency. No bruits were bowel sounds were increased in frequency. No bruits were heard.heard.

Liver was not palpable under the costal margin and its span Liver was not palpable under the costal margin and its span is approximately 9cm. is approximately 9cm.

Spleen was not palpable under the costal margin and there Spleen was not palpable under the costal margin and there was resonance on percussion of Traube’s space.was resonance on percussion of Traube’s space.

His kidneys were not ballotable and renal punch was His kidneys were not ballotable and renal punch was negative on both sides. negative on both sides.

Per Rectal ExaminationPer Rectal Examination

His prostate gland was not enlarged His prostate gland was not enlarged and there were no palpable masses. and there were no palpable masses. There was no rectal bleeding and no There was no rectal bleeding and no malaenamalaena..

Lower LimbsLower Limbs

equal, normal temperature on both equal, normal temperature on both sides, no tenderness and no ulcers. sides, no tenderness and no ulcers.

There was no pedal edema; There was no pedal edema; Dorsalis pedis and Posterior Tibial Dorsalis pedis and Posterior Tibial

pulses were palpable, regular in pulses were palpable, regular in rhythm, of strong volume and rhythm, of strong volume and symmetrical on both sides.symmetrical on both sides.

CNS examinationCNS examination

There was no tenderness of the joints or There was no tenderness of the joints or muscles. There was slight muscle wasting muscles. There was slight muscle wasting of his right upper and lower limb. The of his right upper and lower limb. The joints had normal range of movement. joints had normal range of movement. Muscle tone and power were were Muscle tone and power were were diminished on his right upper and lower diminished on his right upper and lower limb. He exhibited an apraxic gait on his limb. He exhibited an apraxic gait on his right side.Coordination and reflexes were right side.Coordination and reflexes were present and normal. The patient present and normal. The patient responded to light touch and pain. responded to light touch and pain. Proprioception was intact. Mr. BKB Proprioception was intact. Mr. BKB registered at E-4 V-5 M-6, hence 15/15 on registered at E-4 V-5 M-6, hence 15/15 on the Glasgow Coma Scale.the Glasgow Coma Scale.

Provisional Diagnosis: Provisional Diagnosis:

Colorectal CarcinomaColorectal CarcinomaDifferential Diagnosis:Differential Diagnosis:

Inflammatory Bowel DiseaseInflammatory Bowel DiseaseDiverticulitisDiverticulitis

InvestigationsInvestigations

1)ECG: No ischaemic changes1)ECG: No ischaemic changes 2)Colonoscopy done: 1/4/092)Colonoscopy done: 1/4/09 Rectum-No Abnormalities DetectedRectum-No Abnormalities Detected Sigmoid Colon-No Abnormalities DetectedSigmoid Colon-No Abnormalities Detected Descending Colon-No Abnormalities Descending Colon-No Abnormalities

DetectedDetected Transverse Colon-Polyp detected and Transverse Colon-Polyp detected and

removed.removed. Ascending Colon-No Abnormalities DetectedAscending Colon-No Abnormalities Detected

InvestigationsInvestigations

InvestigationsInvestigations

ManagementManagement

1/4/09; 11:00am1/4/09; 11:00amBP: 160/100 mmHg, Pulse: 60bpm, BP: 160/100 mmHg, Pulse: 60bpm,

Temperature:37˚CTemperature:37˚C1)Colonoscopy done: Transverse 1)Colonoscopy done: Transverse

colon polyp found and removed colon polyp found and removed

Final DiagnosisFinal Diagnosis

Transverse Colon Polyp.Transverse Colon Polyp.