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GS II Preceptorials

GS II Preceptorials. January 22, 2012 Block 10a. General Data. 42 y.o. Female Unemployed Roman Catholic Tondo, Manila Chief Complaint: diffuse abdominal pain. History of Present Illness. Worsening of: Diffuse abdominal pain Vomiting, diarrhea

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GS II Preceptorials

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  1. GS II Preceptorials January 22, 2012 Block 10a

  2. General Data • 42 y.o. • Female • Unemployed • Roman Catholic • Tondo, Manila Chief Complaint: diffuse abdominal pain

  3. History of Present Illness

  4. Worsening of: • Diffuse abdominal pain • Vomiting, diarrhea • (+) general body weakness, (+) loss of appetite  PGH-ER History of Present Illness 1 day PTA:

  5. Review of Systems • (-) unexplained weight loss • (-) HA, BOV, cough, colds • (-) chest pain, palpitations, DOB, orthopnea • (-) LOM, joint pain

  6. Past Medical History • (-) co-morbids • s/p LSCS (2003, Metropolitan) for breech presentation • (-) history of trauma • (-)allergies

  7. Family Medical History • (+) HPN – mom • (+) DM – sister • (-) CA, allergies

  8. OB History • Menarche: 14 y.o., w/ subsequent menses occurring at regular monthly intervals. • Menses last for 4-5 days, consuming 3-5 ppd, (-) dysmenorrhea. • LMP: Dec 31, 2011, PMP: November 2011 • G1P1 (1001), s/p LSCS for breech presentation (2003, Metropolitan), (-) FMC

  9. Personal/Social History • (-) vices • HS grad, unemployed • Lives with husband (security guard) and son in a rented apartment in Tondo, Manila

  10. Physical Examination

  11. Physical Examination

  12. Assessment Partial gut obstruction probably secondary to post-operative adhesions

  13. DIAGNOSTICS

  14. BLOOD CHEMISTRY Glucose 4.31 4.1-5.9 BUN 2.8 2.9-9.3 Crea 56 39-91 Albumin 22 35-48 Ca 2.06 2.15-2.50 Mg 0.61 0.74-0.99 Na 136 136-144 K 4.5 3.6-5.1 Cl 98 101-111

  15. CBC WBC: 12.7 5-10 RBC: 4.75 4-6 Hgb: 146 120-170 Hct: 0.443 0.38-0.48 MCV: 93.3 80-100 MCH: 30.6 27.0-31 MCHC: 328 320-360 RDW: 13.1 10.0-16.0 Plt: 406 150-450 Differential Count: Neut: 0.829 0.50-0.75 Lymph: 0.068 0.20-0.50 Mono: 0.097 0.02-0.09 Eos: 0.003 0.01-0.04 Bas: 0.002 0.00-0.01

  16. Abdominal CT-Scan (1/18/12) • Findings: • Small and large bowel loops exhibiting diffuse wall thickening. No intraabdominal masses noted. Minimal fluid is noted in the posterior cul de sac, which may still be physiologic. • The liver, pancreas, and spleen are of normal size and tissue homogeneity. There are no focal masses noted within. • A gastric tube is seen with its tip at the ascending segment of the duodenum. • The gallbladder is unremarkable • There are no enlarged lymph nodes noted • The adrenal glands are normal • The kidneys show good excretory function and are of normal size, position, and configuration. The urinary collecting structures and urinary bladder are normal. • The uterus and adnexa are unremarkable • Reticular densities are noted in the posterolateral quadrant of the visualized right lung base • The heart is enlarged with LV form

  17. Abdominal CT-Scan (1/18/12) • Impression: • DIFFUSE SMALL AND LARGE BOWEL WALL THICKENING, LIKELY INFLAMMATORY • CARDIOMEGALY, LV FORM • NON-SPECIFIC PULMONARY PARENCHYMAL INFILTRATES

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