Mary Krizelle B.

Dejecacion
Level II- ADZU SOM

BEDSIDE OUTPUT
Date and Time of Patient’s Admission: July 1, 2015 , 5:00PM Date and Time of Interview: July 4, 2015; 2:10 PM
Place of Interview: Ward 4, ZCMC Source of Information: Patient

General Data

Name: B.M Occupation: Helper (Laundry)

Age: 56 years old Religion: Roman Catholic
Sex: Female Nationality: Filipino
Address: Ipil, Zambo. Sibugay Civil Status: Married

Chief Complaint:
Abdominal pain

History of Present Illness:

Patient noticed a palpable mass estimated to be about 2 inches in size on her abdomen (RLQ) for about a
year already. Mass is not tender or painful. Patient did not seek consult. No meds were taken.

One (1) month PTA, the patient had onset of productive cough with white phlegm of minimal amount. No
fever and any other associated symptoms. Condition tolerated. No medicines were taken and patient still did not
seek consult.

Two weeks (2) prior to admission, the patient had sudden onset of abdominal pain on the right lower
quadrant radiating to the back. Pain was described as colicky and intermittent with pain scale of 6, duration of
about 5 minutes, patient applies liniment (haplas) to relieve the symptom. No meds were taken. This prompted the
patient to seek consult and was brought to Ipil Doctor’s Hospital and was admitted. UTZ was done and revealed
Right Renal Mass.

One day (1) prior to admission, patient was referred to Zamboanga City Medical Center for further
evaluation and management of the mass.

Upon admission, the mass was noted to be soft, movable, nontender, and located at the right upper
quadrant of the abdomen about 9x9x6 cm. Patient is still coughing but no fever noted. Abdominal pain is still
present but relieved by medications given.

Past Medical History:

Patient had no previous hospitalization and surgery. No known allergies. She takes multivitamins every
day.

Family Medical History:

Patient has no history of heredito-familial diseases such as Diabetes mellitus, hypertension, and cancer.
No one in the family was also diagnosed with tuberculosis.
Personal and Social History

Patient is married to her husband for more than 30 years now and a mother of 7 children. She is a house
helper and does laundry most of the time. She works for more than 8 hours a day. She is a cigarette smoker (0.6
pack years) and drinks alcohol occasionally (1-3 glasses). Her husband is also a smoker. Patient eats everything
provided on the table. Diet consists of vegetables, fish, rice and meat.

REVIEW OF SYSTEMS:

General (-) weight loss , (-) fever, (-) easy fatigability, (-) sleeping disturbances
Skin (-) rash, (-) lumps, (-) itching, (-) dryness
Head (-) dizziness, (+) headache, (-) lightheadedness
(-) pain, (+) blurring of vision (with reading glasses), (-) redness,
Eyes
(-) excessive tearing of the eyes
HEENT
Ears (-) changes in hearing, (-) discharges, (-) pain
Nose (-) colds, (-) epistaxis, (-) discharges
Throat (mouth) (-) pain upon swallowing, (-) hoarseness, (-) bleeding gums
Neck (-) pain, (-) stiffness, (-) mass
Respiratory (+) cough, (-) shortness of breath, (-) difficulty of breathing, (-) chest tightness,
Cardiovascular (-) chest pain, (-) palpitations, (-) orthopnea
(-) pain, (-) anorexia, (-) diarrhea, (-) constipation, (-) hemorrhoids, (-) change in bowel
Gastrointestinal
movement, (-) blood in stool
Genito-Urinary (-) change in urine frequency, (-) dysuria, (-) hematuria, (-) discharges, (-) itchiness
Musculoskeletal (-) weakness, (-) pain, (-) bruises
Peripheral (-) leg cramps, (-) edema, (-) tenderness, (-) numbness or tingling of hands, (-)pain in calf
Vascular
Neurologic (-) irritability, (-) confusion, (-) paralysis, (-) seizures, (-) tremors, (-) paralysis
Hematologic (-) easy brusing, (-) bleeding, (-)anemia, (-) past transfusion
Endocrine (-) cold/heat intolerance, (-) excessive sweating, (-) excessive thirst or hunger

PHYSICAL EXAMINATION:
Patient is conscious, coherent, alert and cooperative. Not in respiratory distress.
General

Blood pressure 130/70 mmHg Pulse rate 84 bpm

Vital signs Respiratory rate 28 bpm Weight 30.4 kg
Temperature 36.6°C O2 sat 92
Skin No cyanosis, lesions, and jaundice. Skin is warm to touch with good skin turgor
No scars and lesions; No facial edema; Normal hair distribution and
Head
texture; Normo-cephalic
Eyes Pale conjunctiva; anicteric sclerae; Pupils equally reactive to light
No lesion; No discharges; Both pinna symmetrical; Both ear canals
HEENT Ears
clear
Pink mucosa; No nasal excoriation or discharges; No tenderness of
Nose
frontal and maxillary sinuses; No alar flaring
Throat (mouth) Tongue midline; No gingival enlargement, Pale buccal mucosa
Neck Trachea midline; No mass; (-) lymphadenopathy
No scars, lesions, erythema noted; No visible masses or deformities
Inspection
noted,
Unequal chest expansion (Chest lag right) No areas of
Palpation
Thorax and Lungs tenderness; Decreased tactile fremitus on right lung
Percussion Less resonant on the right lung field
Decrease breath sounds on right lung field; (+) grunting; no
Auscultation
egophony
Inspection No visible apical pulses
Palpation A dynamic precordium; no heaves or thrills. Apical impulse palpable
Cardiovascular on the 5th ICS at left midclavicular
Auscultation Prominent heart sounds with regular rhythm. No murmurs, rubs or
thrills.
Flat; No surgical scars; No significant lesions; No visible pulsation;
Inspection
No spider angioma; No caput medusa, Abdominal girth: 71 cm
Auscultation Normoactive bowel sounds
Abdomen
Percussion Dull upon percussion on the right, Tymphanic on the LUQ
RLQ-RUQmass, rigidity extending posteriorly, non-tender,
Palpation
hard, non-movable, 9x9x6 cm in size
Genito-Urinary Not examined
Rectal Not examined
Cold to touch; No edema; No cyanosis; No joint deformities; Full range of motion of both
Extremities
upper and lower extremities
Peripheral No edema; (+) clubbing of fingers; No varicosities; Capillary refill time < 2sec;
Vascular
Alert, relaxed and cooperative. Thought process coherent. Oriented to person, time and
Neurologic
place. Reaction to light touch and position intact. Obeys command.

MEDICAL IMPRESSION:
t/c Renal Cell Carcinoma with Chronic Anemia and Pneumonia
BASIS:
History and Review of Systems
 Age: 56 y.o (Peak incidence rate
for renal cell ca: 50-70 yo)
 RLQ abdominal pain radiating to
the back (flank pain)
 Cigarette Smoker
 Cough (>2 weeks)
DIFFERENTIAL DIAGNOSIS:
1. Appendicitis
2. Ectopic Pregnancy
3. Ileocolitis
DIAGNOSTICS/PARACLINICALS:
1. CT scan
- (abdomen and pelvis CT) to confirm diagnosis of renal cell carcinoma, determine the
extent for possible surgery and to rule out other differentials
- (chest CT) to verify metastasis to the lung since Chest X-ray is previously done.
2. Urine analysis and cytology
Physical Examination
 9x9x6 cm RLQ- RUQ
abdominal mass, rigidity
extending posteriorly, non-
tender, hard, non-movable
 Pale conjunctiva, Pale buccal
mucosa
 Unequal chest expansion
(Chest lag right), Less resonant
on the right lung field,
Decrease breath sounds on
right lung field; (+) grunting,
RR: 28bpm
Rule In
(+) RLQ abdominal pain
(+) sudden onset
(+) leukocytosis (WBC: 18.0)
(+) RLQ abdominal pain
(+) sudden onset
(+) abdominal mass
(+) RLQ abdominal pain (colicky)
(+) sudden onset
(+) abdominal mass
(+) leukocytosis (WBC: 18.0)
Paraclinicals
 UTZ: Right renal mass
 CBC:
Low RBC 3.5 x10^12/L
(NV: 4.0-5.5)
High WBC: 18.4
x10^9/L (NV: 5.0-10.0)
 Chest Xray impression
(6/28/15): Pneumonia
both lower lobes, Pleural
reaction Left
Rule Out
(+) Abdominal Mass
 Pain was described as colicky
and intermittent with pain
scale of 6, duration of about 5
minutes, patient applies
liniment (haplas) to relieve
the symptom.
 CT scan result
(-) vaginal bleeding
Menopause (48 years old or 8 years
ago)
UTZ result: Renal Mass
 CT scan result
 -to evaluate kidney function and diagnose what type of renal cancer
3. Complete Blood Count (CBC)
 Used to directly examine the circulating cellular elements of the blood (RBC, WBC, and
platelets).
 Used to provide evidence of inflammatory or infectious conditions.
 To detect and monitor anemia, and to determine patient’s blood type especially if blood
transfusion is warranted.
4. Renal and liver function tests- to further evaluate the liver and kidneys for possible chemother-
apy, to check for possible metastasis
5. Sputum culture
-To confirm pneumonia and for targeted treatment

MANAGEMENT:

 Pain medication

1. Anemia
 Transfusion
 Erythropoeitin (EPO)
2. Renal Cell Carcinoma
 Localized tumors: radical nephrectomy
 Advanced disease: alleviate pain or hemorrhage (Palliative care)
3. Pneumonia
 Antibiotics for specific bacteria