3 Year CPC October 8, 20202

3rd Year CPC October 8, 20202
CLNICAL ABSTRACT
GENERAL DATA:
The patient is a 59 year old female, housewife, Roman Catholic, from Quezon City, admitted for
the first time at a tertiary government hospital last July 24, XXXX
CHIEF COMPLANT
Difficulty of breathing
HISTORY OF PRESENT ILLNESS:

Three weeks prior to admission, patient noted gradual abdominal enlargement described as
tightening of clothes accompanied by crampy, vague, non-radiating, tolerable, waxing and waning
abdominal pain, lasting for few hours, not related to food intake and relieved by bowel movement. She
also experienced four episodes of mucoid, non-bloody and non-foul smelling loose stools amounting to
half a cup per bout. There was no fever, vomiting, jaundice or bladder symptoms noted. She consulted a
private physician who gave a diagnosis of Acute Gastroenteritis. She was prescribed Hydrite tablet as
oral hydrating solution, Loperamide HCl, and Cotrimoxazole 400/80 mg per cap, 1 cap BID for 1 week,
taken compliantly with relief of diarrhea.
Two weeks prior to admission, abdominal pain persisted accompanied by loss of appetite, early
satiety, abdominal fullness, and decrease in the caliber of stool. There was no melena or hematochezia.
This prompted another consult; however, diagnosis was unknown to the patient. She was give analgesics
with slight relief of pain noted.
Five days prior to admission, she then experienced difficulty of breathing after doing household
chores accompanied by 2-3 pillow orthopnea, pleuritic chest pain, vomiting of 1 episode per day of
previously ingested food as non-blood and non-bilous amounting to 1 cup per bout. There was no fever,
cough, colds, PND or edema. Previously requested ancillary procedures were done revealing multiple
cholelithiasis, moderate ascites, and pleural effusion, right on abdominal UTZ. SFA showed ileus.
Likewise, CXR revealed massive pleural effusion on the right hemithorax however, hidden mass cannot be
totally ruled out. No diagnosis was given to the patient. She was advised admission for thoracentesis at
same hospital, patient opted transfer to this institution hence admitted.
REVIEW OF SYSTEMS
40% weight loss in two months No dysuria, no frequency, no urgency
No loss of consciousness, no seizures No polyuria, no polyphagia, no polydipsia
No neck masses, no hoarseness No palpitations
No bleeding tendencies, no easy bruisability
PAST MEDICAL HISTORY

No PTB, diabetes, hypertension No asthma, allergy
No previous surgery or any hospitalizations
FAMILY HISTORY
(+) HPN – mother No diabetes, asthma, allergy, cancer
PERSONAL AND SOCIAL HISTORY

Non-smoker Non-alcoholic beverage drinker
Unemployed and stays at home all the time No history of travel
OB-GYNE HISTORY
G5P5 (5001); Her 4 children died of infection the early childhood
First sexual contact at 21 years old; No dyspareunia, no post-coital bleeding, no AUB or STD
No history of OCP intake; Menopause at 49 years old with no regular consult
PHYSICAL EXAMINATION
Conscious, coherent, speaks in phrases
o
BP=110/70 CR=98 RR=31/min T=35 C
Warm moist skin, no active dermatoses, no skin lesions
Pink palpebral conjunctivae, anicteric sclerae
Moist lips and buccal mucosa, with alar flaring, no naso-aural discharge, no TPC
Supple neck, no neck vein engorgement, no masses, no lymphadenopathy
(+) chest lag on the right, with supraclavicular retraction, dullness on the right lung field with
decrease breath sounds at the level of the scapular spine
th
Adynamic precordium, normal rate and regular rhythm, AB at 5 LICS MCL, no murmurs
Abdomen was slightly distended, with hypoactive bowel sounds, liver dullness not assessed,
Traube's space not obliterated, dull on percussion, no shifting dullness, soft and tender on all
quadrants, with no rebound tenderness
DRE: no skin tags, no fissure, tight spincteric tone, smooth rectal mucosa, non-tender, with
palpable irregular mass at the anterior pararectal area measuring 4.0 x 5.0 cm., non-tender, with
brown stools on examining finger
No cyanosis, edema, pallor; Pulses full and equal
LABORATORIES AND ANCILLARY PROCEDURES
7/24 7/27 Normal Value

CBC Hgb 123 120-150gm\L
Hct 0.38 .38-.48
WBC 11.1 5-10 x 109\L
PMN 0.74 0.45-0.65
Lymphos 0.25 0.25-0.40
Eos 0.01 0.02-0.04
Protime 38.9 sec. 14-18 sec
control 12.5 sec.
% activity 22.3
INR 3.54
RBS 7.1 3.9-6.1mmol\L
BUN 7.44 2.5-6.4mmol\L
Creatinine 44.79 53-115umol\L
Na 134.9 144.46 140-148mmol\L
K 3.9 3.4 3.6-5.2mmol\L
SGOT 18.18 15-37U\L
SGPT 23.53 30-65U\L
Alk Phosphatase 87.74 50-136U\L
Total Protein 55.35 51.57 64-82g\L
Albumin 25 26.59 34-50g\L
Globulin 30.34 30.78 25-35g\L
A/G 0.8:1 0.67:1 1.5-2.5:1
TVUS (7/24)
small retroverted uterus
Myoma uteri
Thin endometrium
Posterior cul-de-sac mass
Dilated bowel loops
12-L ECG
Sinus tachycardia
Non-specific ST-T wave changes
SFA
localized ileus, L hemiabdomen
CXR
pleural effusion or atelectasis;
right hidden mass cannot be totally
ruled out
PLEURAL FLUID ANALYSIS (7/24)

Gross brown, turbid
RBC count numerous
6
WBC count 18 x 10 /L
PMN 0.86
Lymphos 0.14
Sugar 8.06
Protein 75.9
GRAM STAIN 0-1/hpf

no microorganism seen
C/S: No growth after 36 hours
AFB: Negative
COURSE IN THE WARD

On admission, patient was in respiratory distress, tachypneic, normotensive with normal
cardiac rate. Routine laboratories were done. Abdominal CT scan was requested but was not done.
She was referred to OB-gyne with no pathologic finding noted, however, they requested for
transvaginal ultrasound revealing myoma uteri, thin endometrium with posterior cul-de-sac mass.
She underwent diagnostic and therapeutic thoracentesis and obtained 850.0 ml of brownish colored
pleural fluid. There was relief of respiratory distress after the procedure. Specimen was then sent
for analysis. Post-thoracentesis CXR revealed no significant change. Fleet enema was likewise done
with passage of brown, soft stool approximately 250.0 ml.
On the 2nd HD, she had one episode of bowel movement and vomiting of previously ingested
food with stable vital signs. NGT was inserted and she was placed on NPO. Brownish material per
NGT was noted amounting to 100.0 ml. Referral to GI service for evaluation was done with an
impression of Partial Intestinal Obstruction probably secondary to colonic mass. She was likewise
referred to surgery with same impression probably secondary to colorectal mass. The plan was to do
proctosigmoidoscopy. Repeat SFA was done revealing intestinal obstruction. She was started on
Metronidazole, Cefuroxime and vitamin K.
On the 3rd HD, patient was in respiratory distress, tachypneic, tachycardic and normotensive.
Examination of the chest revealed the same decreased breath sounds on the right lung field.
Reaccumulation of pleural fluid was entertained. Repeat thoracentesis was done but a dry tap was
obtained. ABG and 12 L ECG were requested. The patient went into CP arrest. Relatives then
consented for an autopsy.

3 Year CPC October 8, 20202

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3rd Year CPC October 8, 20202

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY

PERSONAL AND SOCIAL HISTORY

LABORATORIES AND ANCILLARY PROCEDURES

7/24 7/27 Normal Value

PLEURAL FLUID ANALYSIS (7/24)

GRAM STAIN 0-1/hpf

C/S: No growth after 36 hours

COURSE IN THE WARD

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