CASE MANAGEMENT PRESENTATION AND SHARING OF INFORMATION ON A 59/M WITH LOWER GI BLEEDING

TUESDAY, JULY 18, 2006, 9:30 – 10:30 AM
DEPARTMENT OF SURGERY
CONFERENCE ROOM



CASE PROTOCOL

This is a case of R.D., a 59 year old, male from Pampanga who came in due to passage of blood per rectum.

HISTORY OF PRESENT ILLNESS:
Four months prior to consultation, patient passed out blood per rectum which is sometimes accompanied by soft feces. There were no other associated symptoms like abdominal pain, vomiting, nausea, weight loss and fever. Patient sought consult at a private doctor where diagnosis was unknown. Patient was then lost to follow up.
Persistence of passage of blood per rectum prompted consult and admission.

PAST MEDICAL HISTORY:
No previous hospitalization/operation
No known allergies to food and drugs
No history of HTN, asthma, PTB, heart disease
No history of CA

FAMILY HISTORY:
No known heredofamilial disease

PERSONAL/SOCIAL HISTORY:
Previous smoker (50 pack years), stopped 10 years ago
Beer drinker (2-3 bottles per day)

REVIEW OF SYSTEMS:
No weight loss, no anorexia
No blurring of vision, no tinnitus
No cough, no colds, (+) history of dyspnea, no easy fatigability
No chest pain, no palpitations, no orthopnea, no PND
(+) frequency, no urgency, no dysuria, no hematuria
No seizures

PHYSICAL EXAMINATION:
Patient is conscious, coherent and not in cardiorespiratory distress
BP: 140/80 mmHg
PR: 78 bpm
RR: 19 cpm
Temp: 37.1 oC

HEENT: anicteric sclera, pink palpebral conjunctiva, no NAD, no TPC, no CLAD, no carotid brisk
Chest and Lungs: symmetrical chest expansion, no retractions, no lagging, clear breath sounds
Heart: adynamic precordium, PMI at 5th ICS left MCL, normal rate, regular rhythm, no murmurs
Abdomen: flat, normoactive bowel sounds, soft, nontender
Extremities: grossly normal, full and equal pulses, no edema, no cyanosis
DRE: no skin tags, no fissures, empty, non-collapsed rectal vault, (+) masses, no tenderness, (+) blood per palpating finger.

ASSESSMENT: lower GI bleeding probably secondary to colorectal CA

COURSE IN THE WARDS:
Patient underwent colonoscopy with biopsy, and eventually an operation, particularly Low Anterior Resection. Intra-op findings noted a fungating mass causing 80% obstructing on the distal sigmoid.