General Data

A Thai male, 49 years old, Thai nationality, married, Muslim, occupation as a businessman, currently residing in Bangkok, was admitted at Lerdsin Hospital on 27th August 2012.

Chief Complaint
Abdominal pain, 10 hours duration

History of Present Illness

3 days prior to admission, patient experienced difficulty in defecating, 1 episode per day and feeling of bloating with mild abdominal discomfort. The stool itself was dark brown and of hardened consistency mixed with mucus. There were no associated symptoms of fever, rectal mass, anorexia, nausea, vomiting, diarrhea and pain during defecation. The patient did not take any medications to improve the constipation. 10 hours prior to admission, the abdominal discomfort progressed to moderate generalized abdominal pain. The pain was described as continuous in nature, colicky in character, with no radiation and was not associated with position or food intake. This was associated with inability to defecate (constipation). He was able to pass gas/flatulence total of 1 time that day. 7 hours prior to admission, the generalized abdominal pain worsened and was now accompanied by nausea and vomiting. Patient vomited total of 8 times. The vomiting was not associated with food intake. The vomitus was non bilious, with some food particles, no blood content. Patient did not have fever, any recent weight change. Patient has a history of recent bowel habit change for the past 3 years. Patients stomach pain became unbearable prompting him to come in to Lerdsin Hospital for a consultation and was advised admission.

Past History
Childhood Illness: Does not remember any childhood illnesses and has no major illness that required hospitalization. No history of any drug intake and no history of ionizing radiation exposure. History of complete immunization/vaccinations. Adult Illness: Underlying diseases Controlled Hypertension, controlled Diabetes Mellitus type II with medication and dyslipidemia Colorectal cancer S/P Lower anterior resection (January 2012) with Chemotherapy + Radiation

Taking anti-hypertensive drug and DM medications regularly: Metformin (500 mg) Enalapril (5 mg) Simvastatin (20 mg) Sig. 1 x 1 PO pc Sig. x 1 PO pc Sig. x 1 PO hs

No over the counter medications or supplements Surgical History: Lower anterior resection for CA colon January 2012 Psychiatric History: None

Family History
No family history of diabetes, tuberculosis, thyroid abnormalities, heart disease, anemia, epilepsy, or mental illnesses. Family history of colorectal CA father diagnosed at the age of 50 years old. Patient has 1 sibling, who is well and alive with no illnesses.

Drug or Food Allergies

Patient denies any drug or food allergies

Personal and Social History

Patient is born and raised in Bangkok. Patient is currently residing with his spouse, offspring, and the in laws. Educational attainment college graduate. Married at the age of 25, and currently have one offspring; a 17 years old son. No recent history of travelling to provinces. No history of smoking. No history of alcohol consumption. No history of ionizing radiation exposure.

Review of Systems
General: (-) weakness, (-) fatigue, (-) weight loss, (-) fever, (-) chills, (-) sweats Skin: (-) rash, (-) pruritus, (-) pigmentation, (-) lumps, (-) sores, (-) dryness, (-) change in hair and nails textures HEENT: (-) headache, (-) dizziness, (-) light headedness, (-) vision problems, (-) glasses or contact lenses, (-) eye pain, (-) redness, (-) excessive tearing, (-) double vision, (-) blurred vision, (-) spots, (-) specks, (-) flashing lights, (-) photophobia, (-) hearing loss, (-) tinnitus, (-) vertigo, (-) earaches, (-) discharges, (-) colds, (-) nasal discharge, (-) nose itching, (-) epistaxis, (-) sinus trouble, (-) pain, (-) obstruction, (-) sense of smell, (-) excessive sneezing Throat: (-) pain, (-) dry mouth, (-) hoarseness, (-) sore throat, (-) bleeding gums, (-) dentures, (-) sore tongue, (-) difficulty in swallowing, (-) pain during swallowing Neck: (-) lumps, (-) swollen glands, (-) pain, (-) stiffness Breast: (-) lumps, (-) pain, (-) discharge, (-) change in color/texture of areolar Respiratory: (-) cough, (-) hemoptysis, (-) shortness of breath, (-) pain, (-) wheezing, (-) sputum, (-) orthopnea, (-) difficulty in breathing, (-) stridor Cardiovascular: (-) heart trouble, (-) heart murmurs, (-) chest pain or discomfort, (-) palpitations, (-) dyspnea, (-) orthopnea, (-) paroxysmal nocturnal dyspnea, (-) edema, (-) easy fatigability, (-) shortness of breath Gastrointestinal: (-) trouble swallowing, (-) heartburn, (-) decrease appetite, (-) nausea, (-) vomiting, (-) hematemesis, (+) change in bowel habits, (-) rectal bleeding, (-) melena, (-) hemorrhoids, (+) constipation, (-)diarrhea, (+)abdominal pain, (-) food intolerance, (-) excessive belching or flatulence Urinary/Genital: (-) bleeding, (-)itching, (-) sores, (-) lumps, (-) change in sexual habits, (-) exposure to sexually transmitted infections, (-) urine dribbling, (-) increased urination frequency, (-) urinary incontinence, (-) oliguria, (-) flank/suprapubic pain Endocrine: (-) heat/cold intolerance, (-) excessive sweating, (-) excessive thirst or hunger, (-)excessive urination,(-) palpitations, (-) tremors Musculoskeletal: (-) muscle or joint pains, (-) cramps, (-) stiffness, (-) tenderness, (-) limitation of motion of joints, (-) trauma, (-) weakness Neurologic: (-) syncope, (-) fainting spells, (-) seizures, (-) paralysis, (-) numbness, (-) tingling or pins or needles sensation, (-) tremors or other involuntary movements, (-) heightened pain Hematologic: (-) pale, (-) easy bruising, (-) bleeding tendencies Psychiatric: (-) excessive nervousness, (-) tension, (-) mood swings, (-) depression, (-) memory change, (-) suicidal attempts

Physical Examinations Vital Signs:

BP: PR: RR: 134/94 mmHg , sitting positin 72 beats per minute 22 breaths per minute

Temp: 37.3o celcius

General Appearance:
The patient is well nourished, with a normal BMI of 21, no gross deformities, afebrile, not pale, not jaundiced, not in acute cardiopulmonary distress, conscious, coherent, oriented to time, place and person, cooperative, with appropriate affect, ambulatory.

Integument / Skin:
Color Brown, no abnormal pigmentations, no pallor, no cyanosis, no jaundice Moisture / Texture Dry and rough Mobility & Turgor Intact skin mobility and good skin turgor Lesions Absent, no rashes visible, no petechiae, no ecchymosis, no spider nevi, no other abnormal venous dilatation, no palmar erythema noted Body hair - Black in color, uniformly distributed Nail beds Pale pink, no clubbing, capillary refill < 2 seconds

HEENT:
Head The hair is black in color, moderately abundant, has smooth texture and is well distributed. The scalp is not movable along the cranium, no lesions, no lice, no scaling, no masses and no tenderness elicited upon palpation. The cranium is normocpehalic, symmetrical and has no deformities. No hematomas were noted. Sutures are non-palpable. Temporal arteries are not visible but palpable with weak pulsations. Face The face is symmetrical. No noted abnormal facies, no spasms, no tics, no other involuntary movements. The patient can also move her facial muscles with ease and has a good and symmetrical facial profile.

Eyes Eyebrows are black in color, thick, well distributed, symmetrical and the growth extends beyond the canthus. Eyelashes are black, short, no matting and are present in both upper and lower eyelids. Eyelids are free from swelling and lesions. No periorbital swelling noted. No nystagmus, no ptosis, no enophthalmos, no exophthalmos, and no lid lag. The conjunctiva is not pale, no visible lesions, and no chemosis. Sclera is anicteric. Cornea is transparent and clear, no opacities, no ulcerations. Iris is round and black in color. The pupils are round and symmetrical, equally reactive to light, 4 mm in size. No opacity of lens, positive for red reflex, no leukocoria, no papilloedema. No tenderness on the eyeballs upon palpation. Ears Ears are symmetrical, triangular in shape, no deformities, no tenderness, and no lesions. External auditory canals are patent bilaterally. The walls are pinkish in color, with no discharge. The tympanic membrane is intact, with visible cone of light, silvery white in color. Nose and nasal cavity Nose is symmetrical, with semi-flaring of the ala nasi, no secretions, and no epistaxis noted. Nasal septum is in the midline, no perforations, absence of nasal polyps, patent nostril ridge. Frontal and maxillary sinuses are non-tender, and positive for transillumination sinus test. Mouth and Throat Lips are symmetrical, pink in color, moist, smooth, no lesions, and no abnormal pigmentations. Buccal mucosa is pinkish, moist, no lesions. Tongue is in the midline, pink in color, no deviation, no lesion. Uvula is in the midline. Tonsils are not enlarged, and pharyngeal wall is not injected. Neck Supple, with trachea in midline, no deviation and intact range of motion of neck. No neck vein engorgement. Regular rate and rhythm of carotid pulse. Thyroid is barely palpable, visible and movable upon swallowing. It is symmetrical, with absence of mass. Upon palpation, the thyroid gland is firm, and smooth in consistency, with isthmus in midline; approximate size of 20 grams. No lymphadenopathy in regional lymph nodes near the nodule (cervical nodes). No bruit audible upon auscultation over thyroid gland. No axillary, epitrochlear and inguinal lymphadenopathy.

Chest and Lungs:

Symmetrical thoracic cage with no abnormal pigmentations, no lesions, no erythema and no deformities. The patient has normal breathing pattern. There is normal widening of ICS, with no intercostals retractions or bulging. Bilateral equal chest expansion with no lagging. There is equal vocal and tactile fremitus bilaterally. Lungs resonant on percussion on all lung field with vesicular breath sounds audible equally on both lungs. No rales, crepitations, wheezes, bronchophony, egophony or other adventitious sounds.

Cardiovascular:
Dynamic precordium with apical impulse located at 5th ICS Left mid-clavicular line on supine position, 2 cm wide. No lifts, thrills and heaves noted on palpation. The patients heartbeat is 72 bpm, regular rate and rhythm. Normally loud S1 and S2 with S1 best heard at the apex and S2 best heard at the base. No murmurs, no gallops audible on auscultation. Bounding jugular vein pulsations; with no neck vein engorgement. Carotid upstrokes are brisk, without bruits. Strong and regular radial, brachial, femoral, popliteal and dorsalis pedia pulse felt equally on both sides (2+)

Abdomen:
Abdomen is distended with no bulging flank, no lesion, no striae, no superficial veins, midline scar of approximately 14 cm (since Jan 2012), umbilicus is inverted, with no visible pulsations, and no visible peristalsis. Hyperactive bowel sounds of 34 bowel sounds per minutes. No bruit audible upon auscultation. Abdomen is soft, with no mass palpable and generalized tenderness upon palpation with marked tenderness especially at left lower quadrant. No rebound tenderness, nor voluntary or involuntary guarding upon palpation. Liver is barely palpable about 1 fingers breadth below the right costal margins with a liver span of 12 cm. Spleen and kidney was not palpable with negative splenic percussion over Traubes space. All 4 quadrants are generally tympanic. Negative costovertebral angle tenderness noted. No ascites and negative for shifting dullness. Digital rectal examination no fissure / fistula / external hemorrhoids/ thrombosed hemorrhoids/ or mass were seen on inspection. Upon digital rectal examination, no mass was palpable, prostate gland was not high riding, and sphincter tone was good. Empty rectum was observed.

Neurologic Exam:
Cerebral

Patient is conscious, coherent, reactive to verbal stimuli, recent and remote memory intact, can recall remote, recent immediate events. Good speech, oriented to time, place and person with good judgment. Patient can follow commands. Cerebellar Patient can perform finger to nose test, negative for Rhombergs, and intact rapid alternating movement. Cranial Nerves: CN1 able to differentiate smell of soap on both nostrils equally CN2 able to read 7mm newsprint at distant 2 feet, both eyes tested separately visual fields intact. No visual field cuts, CN3,4,&6 full range of movement of EOM, pupils are equally reactive to light (direct and consensual) 3 mm. CN 5 - temporal and masseter muscle strength intact; intact corneal reflex CN 7 symmetrical smile, no facial asymmetry, can frown and wrinkle forehead and able to feel pain and light touch sensation on the face. CN 8 hearing intact bilaterally to whispered voice CN 9, & 10 gag reflex intact, uvula in midline CN 11 can shrug both shoulders against resistance; sternocleidomastoid and trapezius muscle strength intact CN 12 tongue in midline, no deviation, no fasciculation. Motor examination Both upper extremities and lower extremities are equal in size (no atrophy) bilaterally. Intact strength in all major muscles; with good bulk and tone of all muscle groups. No tremors, no rigidity, no spasticity and strength are 5/5. Sensory examination Intact pinprick light touch, temperature and pain on both sides equally. Reflexes Deep tendon reflexes Biceps Triceps Left 2+ 2+ Right 2+ 2+

Brachioradialis Patellar Achilles Plantar Pathological reflexes

2+ 2+ 2+ Neg

2+ 2+ 2+ Neg

Negative Babinskis, Negative Kernigs, no nuchal rigidity

Spine and Extremities

Hands and Wrist no nodules, no clubbing of nails, no deformities, no swelling, no tenderness, full range of motion Forearm no deformities, presence no lesions, no atrophy, no swelling, no tenderness, full range of motion Elbow no tenderness on lateral epicondyle, medial epicondyle, and olecranon process, no swelling, no deformities, full range of motion Shoulder no tenderness on clavicle, acromion process, head of the humerus, no swelling, no deformities, full range of motion Cervical Spine no swelling, no deformities, no tenderness, full range of motion Thoraco-Lumbar spine no swelling, no deformities, no tenderness, full range of motion Hip joint no swelling, no deformities, no tenderness, full range of motion. Negative for hammer anvil test, negative for straight leg raising test, and negative for patricks test Knee joint no swelling, negative for crepitus, no tenderness, no deformities, intact full range of motion Ankle no swelling, no deformities, no tenderness, intact full range of motion