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    Ruth Galera
    A 51-year-old female presented with diffuse abdominal pain for 3 days. She reported crampy abdominal pain rated 10/10 with associated fever, nausea, vomiting, and diarrhea. Her symptoms progressed despite taking over-the-counter medications. On examination, she had pale mucosa and globular abdomen without tenderness or signs of peritonitis. Her working diagnosis was cholelithiasis given her history of gallstones. Differential diagnoses included acute pancreatitis, acute gastroenteritis, and thyroid problems. Further diagnostic tests and treatment plans were pending.

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    Last Paper

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    Ruth Galera
    48 views28 pages
    A 51-year-old female presented with diffuse abdominal pain for 3 days. She reported crampy abdominal pain rated 10/10 with associated fever, nausea, vomiting, and diarrhea. Her symptoms progressed despite taking over-the-counter medications. On examination, she had pale mucosa and globular abdomen without tenderness or signs of peritonitis. Her working diagnosis was cholelithiasis given her history of gallstones. Differential diagnoses included acute pancreatitis, acute gastroenteritis, and thyroid problems. Further diagnostic tests and treatment plans were pending.

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    A 51-year-old female presented with diffuse abdominal pain for 3 days. She reported crampy abdominal pain rated 10/10 with associated fever, nausea, vomiting, and diarrhea. Her symptoms progressed despite taking over-the-counter medications. On examination, she had pale mucosa and globular abdomen without tenderness or signs of peritonitis. Her working diagnosis was cholelithiasis given her history of gallstones. Differential diagnoses included acute pancreatitis, acute gastroenteritis, and thyroid problems. Further diagnostic tests and treatment plans were pending.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    48 views28 pages

    Last Paper

    Uploaded by

    Ruth Galera
    A 51-year-old female presented with diffuse abdominal pain for 3 days. She reported crampy abdominal pain rated 10/10 with associated fever, nausea, vomiting, and diarrhea. Her symptoms progressed despite taking over-the-counter medications. On examination, she had pale mucosa and globular abdomen without tenderness or signs of peritonitis. Her working diagnosis was cholelithiasis given her history of gallstones. Differential diagnoses included acute pancreatitis, acute gastroenteritis, and thyroid problems. Further diagnostic tests and treatment plans were pending.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 28

    Internal Medicine

    GENERAL DATA
    • General Data : E.C ,51 yrs old,female,married, Catholic,Antipolo
    • Birthday:Aug. 28,1966
    • Date and Time of Exaination: 2/2/18 - 1;30pm
    • Confined at QMMC Ward on Jan. 27,2018
    CHIEF COMPLAINT
    • CC: “ Diffuse abdominal pain”
    HISTORY OF PRESENT ILLNESS
    • 3 days PTA , patient had a sudden episode of a diffuse crampy
    abdominal pain,VAS 10/10 ,with associated symptoms of
    undocumented intermittent fever ,nausea, nonprojectile vomiting of
    bilous vomitus amounting to 2 cups per episode and two times
    nonbloody diarrhea.

    • pain radiation on shoulder


    • Patient self-medicated with unrecalled dosage of Kremil S ,no consult
    was done
    HISTORY OF PRESENT ILLNESS
    • 1 day PTA ,with progressive symptoms ,hencepatient consulted a local
    clinic.Patient was then advised to be admitted and had take home
    medication of unrecalled dosage of Buscopan , with no relief. Hence
    patient consulted QMMC.
    HISTORY OF PRESENT ILLNESS
    PAST MEDICAL HISTORY

    • (-) Hypertension, (-) Kidney Disease, (-) Diabetes, (-)Tuberculosis, (-)


    Asthma,(-) Allergy, (-) Arthritis (-) Cancer
    • (+) QMMC, diagnosed with Gallstone- Waived Surgery
    • (-) Accidents
    • (-) Surgery, Blood Transfusion
    • (-) allergies
    FAMILY HISTORY

    • (-) Gout ;(-) Hypertension ;(-) Heart Disease; (-) Diabetes; (-) Kidney
    Disease; ; (-) Cancer
    PERSONAL AND SOCIAL HISTORY

    • (-) Smoker
    • (-) Alcohol
    • (-) illicit drug use
    • (-) sexual activity
    • (-)tattoos and body piercing
    PERSONAL AND SOCIAL HISTORY
    • (-) Exercise

    • Living Arrangement: 4 in house


    • OB history : G5P5 (5005)
    REVIEW OF SYSTEMS
    • General : (+) weightloss ( ???? ) ; (+) chills , (+) sWEATS

    • Skin : (-) rashes ; (-) itching ; (-) bruIsing ; (+) PRURITUS

    • HEENT : (+) headache ; (-) syncope; (-) blurring of vision on both eyes
    ; (-) loss of vision ; (-) eye discharge ; (-) ear pain ; (-) deafness ; (-)
    epistaxis; (-) soreness of throat; (-) hoarseness ; (-) dyysphagia , (-)
    odynophagia
    REVIEW OF SYSTEMS
    • Respiratory : (-) wheezing

    • Cardiovascular: (-) palpitation ; (-) cyanosis; (-) edema ; (-) cold


    extremities

    • Gastrointestinal: (-) loss of appettite ;(-) dysphagia ;(-) change in


    bowel habits ;(-) change in stool

    • Genitourinary : (-) dysuria; (-) changes in color of urine; (-) urinary


    retention ; (-) urinary incotinence; (-) dysuria , (-) hematuria ,(-)
    pyuria,(-) incontinence, (-) pain or colic
    REVIEW OF SYSTEMS
    • Musculoskeletal: (-) muscular weakness; (-) atrophy ; (-) night cramps

    • Endocrine : (-) heat and cold intolerance; (-) polyphagia; (-)


    polydipsia; (-) polyuria
    PHYSICAL EXAMINATION
    • Examined on Feb .2 , 2018 (patient’s 6th day of admission)

    • General Survey : awake ,conscious, coherent

    • Vital Signs : BP = 90/70; HR = 99/min ; RR= 25/min; Temp= 36.4


    PHYSICAL EXAMINATION

    • HEENT: hair average texture ; (-) pale conjuctivae; anicteric sclerae;


    (+) pale mucosa
    hearing is good to whispered voice; nasal mucosa is pink,septum
    midline; no tenderness on frontal and maxillary sinuses; oral
    mucosa is pink and pharynx with no exudates; (-) mass on
    anterior neck ; (-) cervical lymph
    - (-) jaundice
    PHYSICAL EXAMINATION
    • Lungs : unremarkable

    • Cardiac: no heaves; no thrills; Apex beat and Point of Maximal


    Impulse (PMI) at the 5th ICS; noted S1 and S2; no adventitious
    heart sounds, regular rate and rhythm;
    PHYSICAL EXAMINATION

    • Abdomen: globular ,non-distended; no lesions and hematoma;


    hypoactive bowel sounds ,(-) tenderness on all quadrants ,(-) Murphy
    ;(-) fluid wave, (-) shifting dullness , (-) Kidney punch
    DDX
    • 1. Chole - more likely sabi ni doc

    • DDX
    • ACUTE PANCREATITIS
    • AGE
    • Thyroid problem

    • Accd sa chart : acute renal failure with anterior neck mass ????
    SALIENT FEATURES
    Primary Working Impression
    DIFFERENTIAL DIAGNOSIS
    MOST LIKELY LESS LIKELY
    MOST LIKELY LESS LIKELY
    MOST LIKELY LESS LIKELY
    DIAGNOSTIC PLAN
    THERAPEUTIC PLAN
    THANK YOU VERY MUCH 

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