GENERAL DATA

• H.C
• 54 years old/female
• Married
• Filipino
• Catholic
• Birth: March 30, 1966 at Manila
CHIEF COMPLAINT
• Abdominal pain
  Patient had abdominal pain (epigastric area)
• colicky in character
• Pain scale of 8/10
• (+) 10 episode of soft to loose watery stool, yellowish
• (+) 2 episode of non projectile vomiting of previously
ingested food ½ cup/bout

Last meal: rice and nilagang “buto-buto

3 days PRIOR TO • (-) bloody mucoid stool, (-) jaundice, (-) fever, (-) dysuria
• Medication taken: Loperamide 4mg capsule
CONSULT
 Patient sought consult at our institution
• Labs: CBC w/ platelet, urinalysis, fecalysis, Na, K
• CBG – 232 mg/dl
• Management:
• NPO temporarily
• PLR 1L x FD 300 ml then 120/hr
• Omeprazole 40 mg TIV
• HNBB 10 mg TIV
• Patient improved and sent home

• Home Medication:
• Omeprazole 40 mg/tab
-30 mins before breakfast
• Ciprofloxacin 500 mg/tab
-BID x 7days
• Bacillus clausii
- 1 vial BID x 5days
During the • (+) loose watery stool
interim • (+) vomiting
• (+) Fever Tmax- 39c
-no medication taken for fever
 • still with above symptoms
• (+) generalized body weakness
Few hours PRIOR TO • Sought consult at our institution
CONSULT
 PAST MEDICAL HISTORY
• (-) Hypertension (+) Diabetes mellitus
• (-) Asthma –metformin 500mg
• (-) Cancer diagnosed 13 years ago
• (-) Cardiovascular disease
• Food or drug Allergies (+) dyslipidemia
• (-) Surgical Procedures -simvastatin 40mg ODHS
• (-) Hospitalization
 FAMILY MEDICAL HISTORY
• (+) Hypertension - maternal
• (+) Diabetes mellitus - paternal
• (-) Asthma
• (-) Cancer
• (-) pulmonary tuberculosis
• (-) Cardiovascular disease
 PERSONAL/SOCIAL HISTORY
• (-) exposure to second hand
smoke
• (-) non smoker
• (-) Alcohol beverage
consumption
• (-) illicit drug abuse
 REVIEW OF SYSTEMS
• General:
[-] chills [-] body malaise [-] easy fatigability

• Integumentary:
[-] pruritus [-] pigmentation [-] pallor [-] lesions

• Head and Neck

[-] diplopia [-] head injuries [-] syncope. [-] blurring of vision [-]
dizziness
 REVIEW OF SYSTEMS
• Respiratory
[-] dyspnea [-] hemoptysis. [-] cough [-] SOB

• Cardiovascular
[-] Palpitation [-] PND [-]Orthopnea

• Genitourinary
[-] dysuria [-]suprapubic pain [-]frequency [-]
incontinence [-] hematuria. [-] oliguria[-] polyuria
 REVIEW OF SYSTEMS
• Musculoskeletal:
[-] muscle pain [-] joint pain and stiffness [-] swelling [-] atrophy
[-] limited ROM

• Neurologic:
[-] syncope [-] seizures [-] tremors [-] numbness

• Endocrine
[-] polyuria [-] polydypsia [-] polyphagia [-] weight loss
[-] heat/cold intolerance [-] excessive thirst

• Hematologic
[-] easy bruisability [-] pallor [-] epistaxis
 PHYSICAL EXAMINATION
• General: • Vital signs:
• Conscious • BP: 110/80mmHg
• Coherent • PR: 80 bpm
• Alert • RR: 20 cpm
• Awake • Temp: 37.5 ℃
• Ambulatory
• not in cardiorespiratory
distress
 PHYSICAL EXAMINATION
• Skin:
• Brown in color
• without hyper or hypopigmentations
• Smooth
• Moist
• warm to touch
• good skin turgor
• Good elasticity
• No lesions
• Nail capillary refill of <2 secs
 PHYSICAL EXAMINATION
• HEENT
• Anicteric sclera
• Pink palpeberal conjunctiva
• No tonsillopharyngeal congestion
• No cervical lymphadenopathy
• No neck vein engorgement
 PHYSICAL EXAMINATION
Chest and Lungs
• Inspection: • Percussion:
• Skin is brown in color • Resonant on all lung fields
• No visible subcutaneous blood vessels
• Thorax is elliptical and symmetrical
• Symmetric chest expansion • Auscultation:
• No intercostal retractions
• No lagging of chest wall on respiration • Vesicular breath sounds
• Breath sounds are clear with no
• Palpation: bronchophony, egophony and
• No masses and no tenderness noted upon
palpation pectoriloquy
• There is equal tactile fremitus on both lung
fields
 PHYSICAL EXAMINATION
Cardiovascular Exam

• Inspection : • Palpation:
• Adynamic precordium • Normal heart rate with regular rhythm
• No abnormal bulging or depressions • S1 loudest at the apex, S2 is loudest at
• Carotid pulse is not visible the base.
• No murmurs heard in the Aortic,
• No neck vein distention.
Pulmonic, Tricuspid and Mitral valves.
• No physiologic splitting.
• Auscultation:
• Apical beat is felt at the 5th
intercostals space.
• No thrills, lifts and heaves noted.
 PHYSICAL EXAMINATION
Abdominal Examination

• Inspection: • Percussion:
• Flat abdomen • Liver span measured as 6-7cm in right
• No scars, rashes and dilated veins noted midcavicular line
• Umbilicus is inverted
• Palpation:
• No visible bulges and peristaltic waves
• With noted direct tenderness on light
• Auscultation: palpation on epigastric area
• Hyperactive bowel sound • (-) murphys sign, psoas sign, obturator
sign, kidney punch test
• (-) negative rebound tenderness
 PHYSICAL EXAMINATION
• Spine and Extremities
• Grossly normal extremities
• No cyanosis, no pallor, no color changes, no edema
• No tenderness, no joint swelling, no nodules
• No limitation of ROM
• No involuntary movements
• Full equal pulses
 PHYSICAL EXAMINATION
• NEUROLOGICAL
• Cerebrum: Conscious; coherent; oriented to time, place and person; cooperative
• Cerebellum: can perform finger to nose test

• Cranial Nerves:
• I – can identify smell of coffee
• II, III – 2-3mm, equal, round, reactive to light
• III,IV,VI – intact EOM
• V – able to clench teeth
• VII – no facial asymmetry
• VIII – can hear whispered words on both ears
• IX, X – uvula at the midline
• XI – can shrug shoulders
• XII – tongue at the midline upon protrusion
 PHYSICAL EXAMINATION
• Motor:
• 5/5 5/5
• 5/5 5/5

• Sensory:
100% 100%
100 % 100%

• Other Signs: (-) Babinski reflex (-) Nuchal Rigidity (-) Brudzinski Sign (-)
Kernigs Sign
 SALIENT FEATURES
• 54/F
• direct tenderness at epigastric area
• Chief complaint of abdominal pain on light palpation
• History of • Hyperactive bowel sound
• (+) loose watery stool
• (+) vomiting
• (+) fever tmax-39 Fecalysis result:
• (+) generalized body weakness • Yellow/ mucoid
• Wbc 1-3
• Rbc- 1-2
• (+)Entamoeba histolytica cyst
DIFFERENTIAL DIAGNOSIS
Differentials Rule in Rule out

Typhoid fever Abdominal pain No headache

Fever, weakness Typidot not done

Hepatitis A Abdominal pain No jaundice

Vomiting Clay colored stool
Low grade fever
dyspepsia Abdominal pain Bloating(full feeling)
vomiting Acid reflux/heartburn
 IMPRESSION
Intestinal amoebiasis; DM type 2