Index patient

Saran and Sabdullah

PART 1. Patient Medical History and Physical Examination

• 1.1 Medical History

• Date and Time of Interview: 21th of December 2018, 6:00 o’clock PM
• A case of V.E, 52 years old, female, married, Filipino, Roman Catholic, born on January 24, 1966,
was raised and currently residing in Sitio Kandingan, Brgy. Pilipog, Cordova, Cebu.
• Informant: patient
• Reliability: 98%
• Chief Complaint: Generalized abdominal pain
• D. History of Present Illness

• Five months prior to admission, patient noticed a tolerable generalized abdominal pain without any
associated symptoms. No consult done. No medications taken.
•
• Three months prior to admission, symptoms persisted thus sought consult at a private clinic in Brgy. Pilipog
and was requested with laboratory and endoscopy. Laboratory and Endoscopy results were unremarkable.
•
• Two months prior to admission, symptom persisted with pain scale of 8/10 now associated with multiple
episodes of loose bowel movements thus decided to sough consult at another private clinic in Lapu-lapu City
and was requested with abdominal ultrasound. The result showed heterogenous mass at the left upper
quadrant thus patient was referred to a surgeon.
•
• Month prior to admission, patient sought consult at OPD Surgery at VSMMC and was requested for a CT scan
and follow-up at CCAP. Upon follow up, patient was told that she has to undergo operation provided that she
has colonoscopy result with biopsy. Thus, patient complied and had colonoscopy at Cebu Doctors Hospital.
Hence admission.
• E. Past Medical History
• The patient claimed to have a complete immunization history and no significant childhood illnesses. The
patient has no known allergies to food and drugs.
• (+) 2018- Colon Ca

• F. Family History
•
• Her husband, 55 years old, is of good mental and physical health and no mention of any significant illness or
present hospitalization.
•
• Her four (4) children, is also of good mental and physical health and no mention of any significant illness or
present hospitalization.
•
• Patient claims no known heredofamilial diseases on her both maternal and paternal side.
• G. Personal, Environmental, and Social History

• The patient is a high school graduate who have been married for thirty (30) years and used to worked
primarily as a factory worker in MEPZA as a electronic parts cleaner prior to being a Barangay Health Worker.
She has four (4) children, three (3) of them are employed, and has two (2) grandchildren. There are total of
six people in her household with a computed crowding index of 2.3. The house is semi-concrete, two story
house. It has a modest size living and dining rooms, three (3) bedrooms, a kitchen and a comfort room.
•
• Prior to her surgical operation, patient claimed that the symptom (abdominal pain), affected her daily living.
She cannot do things she regularly do such as cleaning the house, doing household chores and going to
work. She spends most of her time lying down on her bed if not sitting down on a chair trying to alleviate
the pain.
•
• The surroundings of her house is kept clean and is shaded by several growing trees and plants. It is located
away from sea, creeks, canals but is near a junk dumping site area. They use mineral water for drinking and
use tap water for food preparation.
• 1.2 Review of Systems
•
• General: Energy level good. Not in respiratory distress. (+) report of weight loss in the past months.
• Skin: No lesions, ulcers, rashes or jaundice. No cyanosis or clubbing of nails.
• HEENT: Head – No episodes of dizziness, no history of head trauma, no complaints of headache. Eyes – No
blurring of vision, eye pain, discharges, or diplopia. Ears – No report of ear pain, tinnitus, discharges, or
hearing loss on both ears. Nose – No loss of smell, discharges, obstruction, or epistaxis. Mouth – No
tonsillopharyngeal congestion, mouth sores or gingival bleeding. No hoarseness of voice. No dentures. No
history of tonsillectomy.
• Neck: Lymph nodes not enlarged nor swollen. No thyroid enlargement.
• Breast: No lumps, pain, or nipple discharges.
• Respiratory: No cough, wheezing, or shortness of breath.
• Cardiovascular: No known heart disease, no report of palpitations, murmurs, thrills, or heaves. No chest
pain or discomfort.
• Gastointestinal: No trouble swallowing, no report of polyphagia and no episodes of vomiting. No complaint
of heartburn. No pain upon defecation or reports of rectal bleeding, indigestion, diarrhea, or constipation.
• Genitourinary: No complaint of polyuria. No hematuria, no flank pain or dysuria. No foul-smelling urethral
discharges.
• Peripheral Vascular: No edema on both legs, no report of numbness and intermittent claudication. No
dilated varicose veins or leg cramps.
• Musculoskeletal: No muscle atrophy, no gross joint deformities or joint pain.
• Psychiatric: No history of depression or treatment for psychiatric illness.
• Neurologic: No changes in sensorium, mood, attention, or speech. No changes in orientation, memory,
insight, or judgement. No episodes of dizziness, fainting, or loss of sensation. No seizures, tremors and other
involuntary movements.
• Hematologic: No easy bruising or bleeding. No recent blood transfusion.
• Endocrine: No known thyroid problem. No report of cold or heat intolerance as well as significant weight
gain or loss. No report polyuria and polyphagia.
1.3 Physical Examination
• General: Patient was examined awake, alert, coherent, cooperative, oriented to time, place, and person. She
is well-groomed, afrebrile, not in respiratory distress and not in pain.
• Vital Signs: Temperature - 36.8°C, right axillary; Pulse rate - 80 bpm; Respiratory rate - 19 cpm; Blood
pressure - 110/70 mmHg, right arm; O2 saturation – 98%.
• Skin: Brown, warm, dry, good turgor and mobility; 15 cm midline vertical scar on the abdomen.
• HEENT:
• Head- Normocephalic; Hair of equal distribution and average texture; Scalp without lesions.
• Eyes- Visual fields full by confrontation; Pink conjuctiva and anicteric sclera. Pupils 4 mm constricting to 2
mm, round, regular, and equally reactive to light and accommodation. Extraocular movements intact.
• Ear- Acuity good to whispered voice.
• Nose- Mucosa pink, septum at midline. No sinus tenderness.
• Mouth- Moist oral mucosa. Tongue at the midline on protrusion.
• Neck: Supple;Trachea at the midline;Thyroid gland is barely palpable
• Lymph Nodes: Not enlarged, nontender, with mobile tonsillar and posterior cervical nodes. No
axillary or epitrochlear nodes.
• Breast: Dark areola surrounding the nipple. No extensive fat deposit.
• Respiratory: Adynamic chest wall, symmetrical with good excursion. Lungs resonant to
percussion. Breath sounds vesicular with no adventitious sounds.
• Cardiovascular: AdynamIc precordium. Apical impulse is discrete and tapping, palpable in the
5th left interspace midclavicular line, 8 cm lateral to the midsternal line. No thrills and heaves. Dull
to percussion. Good S1 and S2. Heart beat with regular rate and rhythm. No murmurs. No
distended neck veins, no bruits.
• Abdomen: (+) vertical scar, Flat with normoactive bowel sounds at 12 clicks per minute.
Tympanitic to percussion. Soft with no tenderness or masses. Liver edge smooth, barely palpable
1 cm below the right costal margin. Spleen and kidneys not felt. No costovertebral angle of
tenderness.
• Musculoskeletal: No muscle atrophy and contracture. No joint inflammation and deformities. Good range of
motion on the right hands, wrist, elbow, shoulder, knee, and ankle. Muscle strength is normal for both right
upper and extremities: Right arm – 5/5; Right leg – 5/5, Left arm – 5/5; and Left leg – 5/5.
• Extremities: No edema.
• Peripheral Vascular: No clubbing or cyanosis of finger nails. Capillary refill of 1 second. Pulses (2+ = brisk,
normal). Abdominal aorta not palpable.
Radial Femoral Popliteal Dorsalis pedis Posterior Tibial

Right 2+ 2+ 2+ 2+ 2+

Left 2+ 2+ 2+ 2+ 2+
• Neurologic: Mental status – alert and cooperative. Thought coherent. Oriented to person, time, and place.
Cranial nerves – intact. I – was able to identify scent of alcohol. II – was able to read newsprint. III, IV, VI –
was able to follow the cardinal directions of gaze. V – was able to chew and feel sensations on the forehead,
cheeks, and near the mandibular area. VII – was able to close eyelids, smile, frown, and puff cheeks. VIII –
was able to hear whispered voice. X – active gag reflex. XI – was able to shrug right shoulder against
resistance. XII – was able protrude tongue. Motor – muscle bulk and tone appropriate for age. Cerebellar –
Gait unstable without the use of quad cane. Sensory – pinprick, light touch, position sense, and vibration
intact.
•
• Reflexes:

Biceps Triceps Brachioradiali Patellar Achilles

s
Right 2+ 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+
PART 2. Case Discussion
A. Salient Features and Differential Diagnosis

Salient Features Acute Gastoenteritis IBD CARCINOMA

(Ulcerative Colitis)

Abdominal pain ✔ ✔ ✔

Watery stools ✔ ✔ ✔

Weight loss X ✔ ✔
B. Background of the Disease

• Colon cancer is the most common type of gastrointestinal cancer. It is a multifactorial disease process, with
etiology encompassing genetic factors, environmental exposures (including diet), and inflammatory conditions of
the digestive tract.
• Signs and symptoms
• Colon cancer is now often detected during screening procedures. Other common clinical presentations include
the following:
• Iron-deficiency anemia
• Rectal bleeding
• Abdominal pain
• Change in bowel habits
• Intestinal obstruction or perforation
• Physical findings may include the following:
• Early disease: Nonspecific findings (fatigue, weight loss) or none at all
• advanced disease: Abdominal tenderness, macroscopic rectal bleeding, palpable abdominal mass,
hepatomegaly, ascites
C. Pathogenesis
• Genetically, colorectal cancer represents a complex disease, and genetic alterations are
often associated with progression from premalignant lesion (adenoma) to invasive
adenocarcinoma. Sequence of molecular and genetic events leading to transformation
from adenomatous polyps to overt malignancy has been characterized by Vogelstein and
Fearon.[8]The early event is a mutation of APC(adenomatous polyposis gene), which was
first discovered in individuals with familial adenomatous polyposis (FAP). The protein
encoded by APC is important in the activation of oncogene c-myc and cyclin D1, which
drives the progression to malignant phenotype. Although FAP is a rare hereditary
syndrome accounting for only about 1% of cases of colon cancer, APC mutations are very
frequent in sporadic colorectal cancers.
D. Diagnostic modalities
• Below are some of the laboratory and imaging modalities the patient undergone with the corresponding
results:
• Complete blood count

Result/Unit Reference Range

White Blood Cells 12.0 10^3/uL 4.7-10.3
Lymphocytes 2.4 10^3/uL 0.6-4.9
MID 0.8 10^3/uL 0.3-1.4
GRA 8.9 10^3/uL 2.0-8.1
LYM% 19.8 % 12.7-47.8
MID% 6.3 % 6.3-14.2
GRA% 73.9% 43.5-78.9
Red Blood Cells 4.68 10^6/uL 4.03-5.46
Hemoglobin 9.4 g/dL 12.4-16.8
Hematocrit 29.9 % 36.6-48.3
MCV 64.9 fL 81.5-96.8
MCH 20.4 pg 27.5-33.1
MCHC 31.4 g/dL 32.4-35.7
RDW 17.2 % 11.8-14.9
PLT 475 10^3 /uL 165-385
MPV 7.8fL 7.2-10.2
• Blood Chemistry

• Chest X-ray
FBS
PA Result/Unit
98mg/dL
Reference Range
70-110
• Results were unremarkable
HbA1c 6.0% 4.0-6.0
Total Cholesterol 170.62mg/dL 0-200
Triglycerides 94.75 10-150
HDL 39.58mg/dL 35-60
LDL 56.91mg/dL <130
Creatinine 1.28 mg/dL 0.60 ~ 1.20
Blood Uric Acid 3.09 mg/dL 2.6-6.0
• Abdominal Ultrasound
•
• Measurements:
• Right lobe of liver: 12.4cm
• Gallbladder: 7.3x2 1x2.1 cm WALL 0.1cm
• Right Kidney: 9.6x3.6x0.9cm
• Left Kidney: 9.8x4.6x1.1cm
• Uterus: 5.9x29x3.6cm Endometrial echo: 0.3cm
• The liver, gallbladder, pancreas, spleen, kidneys uterus has normal sonogram
• Except there is a 6.6x8.7x6.3cm heterogenous mass with eccentric medium level echo in the left upper
quadrant of the abdomen. No peristalsis demonstrated.

• IMPRESSION: to consider large bowel etiology, suggest further workup

• CT scan of whole abdomen with contrast

• IMPRESSION:
• Shows heterogenously enhancing circumferential wall thickening (up
to 3.8cm thick and 10cm length) involving the mid descending colon
with intraluminal narrowing and surrounding fat stranding
(infiltration). Consider primary colonic malignancy
• There are small to borderline adjacent left pericolic lymph node
(1cm). Consider lymph node metastasis
• Surgical Pathologic Report Post-op

• DIAGNOSIS
• Tumor site: Descending colon
• Resection specimen: Left hemicolectomy
• Macroscopic depth of Penetration of tumor: Invades the muscularies propria
• Obstruction: yes
• Histologic Tumor type: Adenocarcinoma
• Histologic grade: Moderately Differentiated
• Depth of Infiltration: invades through the muscularis propria into the pericolic tissues[pT3]
• Perforation: No
• Lymph node metastasis: TEN (10) lymph node, negative for metastasis [pN0]
Treatment and Management

• Surgery is the only curative modality for localized colon cancer (stage I-III). Surgical resection
potentially provides the only curative option for patients with limited metastatic disease in liver
and/or lung (stage IV disease) but the proper use of elective colon resections in nonobstructed
patients with stage IV disease is a source of continuing debate.
• Adjuvant chemotherapy is standard for patients with stage III diseases. At present, the role of
radiation therapy is limited to palliative therapy for selected metastatic sites such as bone or brain
metastasis,
• Chemotherapy rather than surgery has been the standard management for patients with metastatic
colorectal cancer. Biological agents have assumed a major role in the treatment of metastatic cases
with selection increasingly guided by genetic analysis of the tumor.

• Left hemicolectomy: For lesions in the splenic flexure and left colon
Part 3. Family Profile
• 3.1 Family Profile
•
• Table 1. Family Profile

Educational
Name Age Civil Status Occupation
Attainment
Vilma Escabas 52 Married High School graduate BHW

Aunalio Escabas 55 Married College level Unemployed

Hanisa Telmoso 25 Single College level Call center agent

Vomer Escabas 25 Single High School Graduate Unemployed

Kheneil Escabas 4 Single

Vom Anthony Escabas 2 Single

• 3.2 Situational Analysis
• The patient is living together with her husband, one (1) child, (1) in-laws, and two (2) grandchildren in Sitio
Kandingan, Barangay Pilipog, Cordova, Cebu. Her house is made from concrete materials and wood. The
house has modest size living and dining rooms, three (3) bedrooms, a kitchen, a comfort room and a small
receiving area for guests.
•
• After her operation, patient felt happy and at ease despite knowing that she had a cancer and operation was
done. She claimed that the doctors advised her for a chemotherapy sessions but the patient declined,
claiming she like to rest for a while and wanted to gain enough strength before going into chemotherapy.
• The family shares a single flush type toilet. They use mineral water for drinking. Communal water source is
being used for bathing, washing dishes, and flushing the toilet.
•
• The primary source of income is allowance from her siblings abroad, and from her own salary.
• 3.3 Family Structure
• The family is an extended type of family comprising of a two or more adults who are related,
either by blood or marriage, living in the same home. This type of family includes married
children and in-laws living together and working toward common goals, such as raising
grandchildren and keeping up with household duties.
• 3.4 Social Class Pattern Behavior
• The family belongs to the middle class family in the social system which believes in hard work,
self-reliance, initiative, independence, responsibility, and economic security. They value a close
family tie bounded by mutual respect and love. They believe that difficult situations can be
overcome if they help one another, either financially or emotionally.
 • 3.5 Family Set-up
• The family exercises democracy within the household where everyone can express their feelings
and emotions, and parents respect their children’s decision and ideas. Tolerance, understanding
and permissiveness prevail. Cooperate can be elicited from every member of the family.
• 3.6 Family Values
• They advocate a close family ties bounded by mutual love and respect. They resolve conflicts by
listening to each other. They also value utang na loob and pakikisama, and puts high value of
education and good work ethics.
• 3.7 Family Beliefs
• All family members are Roman Catholic. Vilma, the patient, goes to mass every Sunday together
with her children and grandchildren and actively participates in religious activities of the church in
the community.
 • 3.8 Impact of the Illness on the Family
• When the head of the family, Vilma had her surgical operation, each member of the family was
affected both financially and emotionally. Luckily, her siblings abroad are generous enough to
help Vilma. However, they did not let the situation disrupt and consume them but instead
became an instrument that held them more closer to each other as understanding, hard work,
and prayers pave the way to recovery.
Family Assessment Tools
• A. Family APGAR
• Table 2. Family APGAR (Wife)
Hardly
Almost Always Some of the Time
Ever
(2) (1)
(0)
I am satisfied that I can turn my
ADAPTATION family for help when something 
is troubling me.
I am satisfied with the way my
PARTNERSHIP family talks on things with me 
and shares problems with me.
I am satisfied that my family
accepts and supports my wishes
GROWTH 
to take on new activities or
directions.
I am satisfied with the way my
family expresses affection and
AFFECTION 
responds to emotion such as
anger, sorrow and love.
I am satisfied with the way my
RESOLVE 
family and I share time together.
• Score: 10 ( Highly Functional Family)
•
• SCORING:
• 8 – 10 = Highly Functional Family
• 4 – 7 = Moderately Dysfunctional Family
• 0 – 3 = Severely Dysfunctional Family
• Table 3. Family APGAR (Children)

Almost Hardly
Some of the Time
Always Ever
(1)
(2) (0)
I am satisfied that I can
turn my family for help
ADAPTATION 
when something is
troubling me.
I am satisfied with the way
my family talks on things
PARTNERSHIP 
with me and shares
problems with me.
I am satisfied that my
family accepts and
GROWTH supports my wishes to 
take on new activities or
directions.
 I am satisfied with the
way my family expresses
AFFECTION affection and responds 
to emotion such as
anger, sorrow and love.

I am satisfied with the

RESOLVE way my family and I share 
time together.

• Score: 10 ( Highly Functional Family)

•
• SCORING:
• 8 – 10 = Highly Functional Family
• 4 – 7 = Moderately Dysfunctional Family
• 0 – 3 = Severely Dysfunctional Family
B. Family Genogram
• C. Family Relationship Evaluation
• Table 4. Family Relationship Evaluation

Name Relationship Age Sex Well Fair Poor

52
Vilma Escabas Patient Female 

Aunalio Escabas Husband 55 Male 

Hanisa Telmoso In-law 25 Female 

Vomer Escabas Son 25 Male 

Kheneil Escabas GrandSon 4 Male 

Vom Anthony Escabas GrandSon 2 Male 

• D. Family SCREEM
• Table 5. Family SCREEM
SCREEM PARAMETERS RESOURCES
Social interact is evident among family members. They
participate in social activities such as fiestas and birthdays.

SOCIAL Family members have well balanced lined of communication

with friends and relatives; have good relationships with
Adequate neighbors and co-workers.

Cultural pride and satisfaction can be identified among

CULTURAL Adequate family members. They have embraced the Filipino and
Cebuano values and apply these in their everyday life.
All family members are Roman Catholic. They attend mass
regularly and participate in religious events in the
RELIGION
community which offers satisfying spiritual experience as
Adequate well as avenue for contacts with relatives and friends.
The family belongs to a middle class family in the social
system. Their monthly income is sometimes not enough to
ECONOMIC
provide the basic necessities of the family as well as for the
Inadequate maintenance medications.
Education of family members is adequate to allow members
to solve difficult situations rationally or comprehend most
EDUCATIONAL Adequate
of the problems that arise within the format of the lifestyle
established by the family.
When medical problems arise, sometimes the family has
MEDICAL Inadequate difficulty with access to consultations, laboratory work-up
and medications due to limited resources.
• E. The SCREEM Family Resources Survey
• Table 6. The SCREEM Family Resources Survey
Strongly Strongly
RESOURCES Questions Agree Disagree
Agree Disagree

We help each other in the family.

SOCIAL We are helped by friends and 
other members of the community

Our culture gives our family

strength. A culture of helping and
CULTURAL 
cooperation in our community
helps our family
Our faith and religion helps our
RELIGION 
family.
Our family’s savings is adequate
ECONOMIC 
for our needs.

Our education/knowledge is
adequate to care for the illness.
EDUCATIONAL 
Our education/knowledge is
adequate to care for the patient.

It is easy to access medical help in

MEDICAL  
our community.
• F. Family Circle

AUNALIO VOMER

VILMA
HANISA KHENEIL

VOM
ANTHONY
• PART 4. Family Action Plan
• Table 7. Family Action Plan
Name/Age/Sex
Vilma Escabas, 52years > post-op site pain
old, female
Development
Assessment Screening Health Education
Monitoring Plan
>Complete and detailed >Assess and evaluate >Counsel the patient
history and physical patient’s ability to cope regarding the disease
examination. with present situation. process and the
importance of
>Neurologic >Assess stressors that
adherence to
examanition. could add up to the
medication and regular
present situation.
>Detailed family history check-up.
of the heredofamilial
>Educate and teach
diseases.
the patient passive
>Vital signs monitoring. range of motion
exercises to prevent
muscle atrophy.
>Provide options
through referral
system for the patient
to avail on programs by
the government.
Documentation