Chief Complaint:
Recurrent lower abdominal pain for 1 year duration.
History of Present Illness:
Patient was well until 1 year ago, in which he developed lower abdominal pain. It was a dull ache at the suprapubic region, radiating to the left upper quadrant. The pain would last for about 3-4 hours at a time, with complete spontaneous relief for a few hours {patient could not quantify}. There is difficulty in ambulation when he experiences pain. The pain is aggravated by movement, and relieved by lying down and massaging his lower abdomen. The painful episodes last for 2-3 days at a time, on average for about once a week.
Abdominal pain was associated with nausea and vomiting, with a total of about 2-3 times per day. He would each vomit out less than half a cup each time, containing clear fluid, and no yellowing material or blood. There was also no vomiting of feces throughout his illness.
His illness was also associated with constipation, with similar onset as his abdominal pain. The patient was not able to properly recall his bowel habits prior to illness. Since his illness, the patient would only pass feces 1-2 times a week. There was also difficulty in passing flatus that would occur occasionally. The stool was “coal” black in color, very foul smelling, but was not hard. Size of feces was reduced. He also experienced incomplete sensation of defecation, and he regularly goes to the toilet but unable to defecate. There was no frank blood in stool.
From the beginning of illness, he also noticed a mass at his abdomen at the suprapubic region. Initially, it was 1 cm in diameter. It was non-mobile, non-tender, and there was no warmth.
There was a history of urgency. He also claimed a history of frequency, but was unable to properly quantify the difference in urination before and during illness, but claimed night urination. There was no history of pain during micturition, dribbling, or micturition.
Since the illness, the pain intensified and the mass increased in size. Prior to admission, the pain radiated also to the back. The abdominal pain was also occasionally felt throughout the abdomen.
2 months prior to admission, he noticed a yellowish discoloration of his skin while looking into the mirror. There was no history of bone pain or shortness of breath.
His illness was associated with loss of weight and loss of appetite. He was unable, however, to quantify the loss of weight. The disease was associated with moderate fever during pain, which itself was associated with chills, and was worse during the day. There was no history of lethargy, leg swelling, visual disturbances, or dizziness. There was however, occasional palpitations.
He began to seek medical attention after around 6 months of illness by going to see a general practitioner. However, he was only given pain medication 2 times. On the 3rd time, he was then referred to HTAA.
In HTAA, he was assessed and investigated. On PR examination, he was told by the doctor that he had per rectal bleeding but no malena was noted by the doctor. Blood samples were taken, but he did not know the significance of those tests. He denied an endoscopic examination was done, but case notes showed that a colonoscopy was done, revealing a mass present from 5 cm from the anal verge to right below the rectosigmoid junction. Imaging studies were also conducted, most probably a CT scan based on his description, but he did not know the results from that study. However, the CT scan was conducted after the surgery and not before as explained by the patient. In his history he denied vomiting out anything but clear vomitus, but nasogastric tube suctioning revealed feces in his stomach, which he denied during history taking. During the admission, he was incidentally found to be diabetic and hypertensive. The patient was until now unaware, but he was also incidentally found to have a right bundle branch block. However, when asked, he did complain of occasional dull chest pain felt at the right side of his chest, aggravated by movement, and relieved by rest.
And emergency laparotomy was done to relieve the patient of intestinal obstruction. However, during the surgery, the patient’s blood pressure was unstable throughout, fluctuating. A Hartmann procedure was done, and the rectal tumor was left intact. Enlarged mesenteric lymph nodes were noted, as well as liver metastases. After the emergency laparotomy, the patient was promptly admitted into the intensive care unit due to his unstable cardiovascular function, and was then transfered out 1 week later.
After the surgery did the patient know that he has a colorectal tumor. However, he does not know the reason for the type of surgery (emergency/elective) or the status of the tumor. Logically he also does not know why the tumor was not resected. There was no history of blood transfusions before or after surgery. The patient also denied history of ICU admission, to which he was admitted after surgery and transfered out from 1 week later due to his unstable cardiovascular function.
3 weeks after the surgery, the patient began chemotherapy, with the first cycle of the Mayo regime. The patient does not know the function of the chemotherapy, the number of cycles, nor the time for the next cycle.
The patient was also advised for future palliative surgery, but the patient does not know the function of the surgery. The patient’s decision kept fluctuating between agreeing and disagreeing since then. He is also displeased with the fact of having a colostomy.
Since the operation, the patient has had reduced abdominal pain, and can readily ambulate. There was no more fever. His appetite has not fully returned yet. The stool in his colostomy bag was brownish in color, and claims mild per rectal bleeding.
He was discharged from the hospital only after settling his welfare issues after more than 1 week of completing his first Mayo regime cycle.
Systemic Review (not reviewed in history of present illness):
General - No further loss of weight.
Skin - No rashes/ulcers
Eyes - No redness/itchiness/discharge
Ears - No pain/discharge/bleeding
Mouth, throat - No ulcers/bleeding/soreness
Neck - No swellings
Respiratory - No cough/shortness of breath/noisy breathing
Cardiovascular - Still having occasional chest pain on the right side of the chest, dull, relieved by rest, not severe (patient can still perform activities), no orthopnea
Hepatobiliary - Reduced jaundice compared to beginning of illness, no urine changes
Hemopoietic - No bleeding tendencies, repeated infections
Urogenital - No incontinence
Musculoskeletal - No pain, weakness or abnormal movement of joints
Neurological - No numbness, weakness, incoordination, abnormal sensation, fits
Past Medical History:
Other than diabetes mellitus, hypertension and right bundle branch block found incidentally during assessment for this illness, he has no other medical issues.
Family History:
He has 3 children, of which the first two died young (at 4 and 8 years respectively). He is not aware of the status of his 3rd child and wife since migrating here.
He has no family history of cancer.
His sister has a history of pneumonia.
Dietary History:
Prior to his illness, he ate a diet consisting heavily in cow and lamb meat, and especially likes burgers. Since the illness he eats a diet mainly of porridge only.
Social History:
The patient was an ex-smoker for 20 years, smoking about 10-15 cigarettes per day.
He migrated alone at 40 years of age to Malaysia from Indonesia in search of money. He has worked as a laborer and security guard. He has been unemployed for 2 years now, surviving on donation money, totaling about 10-20 Ringgit per day. He actively follows the tabligh movement, which allows him additional free food and money.
He lives in an apartment in Batu Lima with 2 others, who are currently employed. Since this illness, he has been under the care of the welfare authority and is currently waiting for that matter to be settled prior to discharge.
No comments:
Post a Comment