Cagayan State University

COLLEGE OF MEDICINE
Carig Campus, Tuguegarao City

SURGERY WARD

Submitted by: MD3 Alpha A1 Group 1:

Agbugay, Rishi Jamivie D.
Aguisanda, Estephanie P.
Andrews, Doll Suzanne
Asanias, Stephen Michael M.
Ayang-ang, Bjorn Gilbert
Bernales, Arfe Jane N.

Submitted to:
Dr. Jhorell Cadang

PATIENT’S PROFILE

Name (Initials) : E.G.

Age : 48 y.o.

Gender : Male

Marital Status : Married

Address : Peñablanca, Cagayan

Birth date : June 27, 1971

Birthplace : Peñablanca, Cagayan

Religion : Roman Catholic

Occupation : Farmer/Carpenter

Nationality : Filipino
 Date of Admission : September 7, 2019

Date/Time of Interview : September 18, 2019, 8:20 AM

Informant (Reliability) : Patient (95%)

Chief Complaint
Pain in the Umbilical Area radiating to all quadrants of Abdomen

HEALTH HISTORY
History of Present Illness:
• 10 days PTA, it was afternoon, the patient was sitting at home when he suddenly
felt pain in his abdomen (Umbilical Area) for a few minutes and the pain went
away, then he experienced defecating of hard, pebble-like stools. He felt pain
while defecating. No fever, headache was noted. Blood was seen while passing
stool. The patient did not seek any medical consultation.
• 4 days PTA, it was morning of September 4, while the patient is busy working as
a carpenter in a construction site; he suddenly felt pain on the umbilical area with
a pain severity of 7/10. He tried to relieve the pain by resting from work. The
pain is on and off for a few hours. After that, the patient felt the pain again but
with progressive non-relieving pain severity of 10/10 that’s the only time he
seeks medical consultation in People’s General Hospital. He has undergone
laboratory examinations, was admitted, and was given medications. The patient
cannot recall the given medications and according to him, he still experiencing
defecating of hard, pebble-like stools.
• Few hours PTA, after 4 days of his admission in People’s GH, he still felt pain in
the abdomen, felt numbing in the lumbar area of his back, and due to lack of
facilities, he was referred to CVMC for further diagnostics exam and was
admitted.

Past Medical History

• Childhood Illness: The patient had chicken pox and measles.
• Adult Illness:
o Medical: None
o Surgical: None
o Psychiatric: None
• Health Maintenance:
o Immunizations: The patient cannot remember having any vaccinations
• Screening Tests: None
Family History
• Father has undergone operation before because of a certain gastric problem which was
unidentified by the patient.
• Mother has a history of hypertension

Personal and Social History

• The patient is a farmer and a carpenter who lives with his wife and 5 children in Penablanca
Cagayan.
• He prefers eating meaty, fatty and salty food and drinking sodas.
• At age 20 years old, the patient started smoking with an average of 14 packs per year and drinks
alcohol particularly “gin bilog” through the years.
• He quit smoking and drinking alcohol 2 years ago.

Review of Systems

• Constitutional: Weight loss due to illness and experienced having fever and chills
• Integumentary: no unusual change in color, (-) rashes, (-) lumps, (-) itchiness or scaling

• HEAD: With headache, dizziness and light-headedness.

• EYES: No eye pain, lacrimation nor redness seen.
• EARS: No earaches, discharge, tinnitus, vertigo, impaired hearing, and itching
• NOSE: No epistaxis, congestion, discharge, itchiness
• MOUTH AND THROAT: No swelling, gum bleeding, or sore throat
• Neck: No pain, lumps nor stiffness
• Breast: No pain, lumps, nor discharge
• Respiratory: (-) cough, (-) sputum production, dyspnea nor hemoptysis,
• Cardiovascular: (-) chest pain, (-) palpitation,(-) easy fatigability,
• (-) orthopnea, (-) high blood pressure
• Gastrointestinal: With loss of appetite; (+) abdominal pain, (+)change in bowel habit,
(+) tenesmus, (-) vomiting, (-)nausea, (-)hematemesis

• Renal: No polyuria, dysuria, hematuria, urinary urgency, oliguria, nocturia, nor

incontinence

• Genital: No pain, discharge, nor swelling

• Hematologic: No pallor, easy bruising, hematoma, nor prolonged bleeding
• Musculoskeletal: With backache, no muscle weakness, varicose veins and
muscle pain in lower extremities
• Neurologic: No memory loss, nervousness, seizures, numbness, tingling,
speech problem, nor sensorial changes
• Psychiatric: No nervousness, anxiety, depression, hallucinations or any
psychiatric disorders
PHYSICAL EXAM
General Survey:
 The patient is conscious, coherent, cooperative, tan skin and lying on the bed with an IV
Sodium Chloride infused on the left arm.
Vital Signs:
• Blood pressure: 90/60 mmHg
• Pulse Rate: 62 bpm
• Respiratory Rate: 16 cpm
• Temperature: 36.7 °C
• O2 sat: 98%
Integumentary:
 (+) gross pallor, no presence of abrasions / scar. No suspicious masses, lesions or nevi,
Head
· Smooth hair texture, no palpable masses nor tenderness
HEENT:
• Eyes
• Pupils are equal and round, reactive to light and accommodation. With whitish sclera and
pinkish conjuctiva
• Ears:
• Both auricles are symmetrical, no external deformities nor lumps, skin lesions, pain,
discharge, nor inflammation observed.
• Nose:
• Nose is symmetric. There were no obstructions, exudates, or signs of inflammation, with
the nasal septum midline.
• No redness in the nasal mucosa. No tenderness in the frontal and maxillary sinuses.

• Mouth and throat:

• Lips are symmetrical, with no lumps, ulcers, or masses in the mouth. Pharynx has no
lesions, exudates and erythema. Palatine tonsils were equal in size, pharyngeal opening
was not constricted. Uvula is in midline.
Neck:
• Trachea is in midline, no palpable lymph nodes.
Thorax and lungs:
• Resonant sound was heard. Breath sounds are vesicular with no added sounds. No
wheezes, rhonchi, rales or rubs
Cardiovascular:
• S1, S2, normal rhythm, no murmur, no rub, no gallops; no thrills, no displacement of
PMI; no carotid bruits.
Breast:
• Symmetric. No masses; No discharge
Abdomen:
• No scarring or stretch marks seen. Normal bowel sounds. Dull on percussion. Palpable
mass on LLQ approximately 5cm by 2.5cm. (+) abdominal tenderness
Extremities:
• Grossly normal limbs. No tenderness. Good range of motion in all extremities. No
observable edema.
Musculoskeletal:
• no joint deformities
 Neurologic
• Cranial nerves are intact. Well oriented to person, place and time

Motor:

• 5/5 in both upper and lower extremities, with normal reflexes

SALIENT FEATURES:

 Male with presenting symptoms of

 Tenesmus
 Change in bowel habits
 Rectal bleeding
 Abdominal pain
 Weight loss
 Palpable mass
 Abdominal tenderness
 Loss of appetite
 Back pain

INITIAL IMPRESSION: Rectal mass possible Colorectal CA

DIFFERNTIAL DIGNOSIS

IRRITABLE BOWEL SYNDROME - is a functional gastrointestinal (GI) disorder characterized

by abdominal pain and altered bowel habits in the absence of a specific and unique
organic pathology, although microscopic inflammation has been documented in some
patients. 

RULE IN RULE OUT

(+) altered bowel habits (-) weight loss
(+) abdominal pain (-)tenesmus
(+) abdominal distention (-)palpable mass
(+) rectal bleeding (-)back pain

HEMORRHOIDS – are swollen blood vessels in the lower rectum. The walls of these blood
vessels stretch so thin that the veins bulge and get irritated on defecation

RULE IN RULE OUT

(+)rectal bleeding (-)weight loss
(-)palpable mass
(-)back pain
 (-) tenesmus
(-) loss of appetite
(-) abdominal pain
gender

DIVERTICULITIS –infection of diverticula which are small pouches in the large intestinal wall that
may involve anything from small abscess in one or more of the pouches to a massive infection
or perforation of the bowel

RULE IN RULE OUT

(+) changes in bowel habits (-)weight loss
(+)abdominal pain (-)palpable mass
(+) vomiting (-)back pain
(+)abdominal tenderness (-) tenesmus
(-) loss of appetite

PATHOPHYSIOLOGY

Normal epithelium

APC

Dysplastic Epithelium

Early Adenoma
K-RAS

Intermediate Adenoma
DCC/DPC4/JV18

Late Adenoma
P53

Carcinma

Metastasis
 Other changes

ETIOLOGY

1. Inherited Gene Mutation- A portion of colorectal cancers are caused by inherited gene
mutations. For example:
 Familial adenomatous polyposis (FAP), attenuated FAP (AFAP), and Gardner
syndrome- caused by inherited changes in the APC gene, a tumor suppressor
gene that normally helps regulate cell division
 Lynch syndrome (hereditary non-polyposis colon cancer, or HNPCC)- A mutation
in one of the DNA repair enzyme genes like MLH1, MSH2, MLH3, MSH6, PMS1,
and PMS2 can allow DNA errors to go unfixed.
 Peutz-Jeghers syndrome- caused by inherited STK11(LKB1) gene, a tumor
suppressor gene
 MYH- associated polyposis (MAP)- caused by mutations in the MYH gene, which
is involved in fixing DNA errors in cell division

2. Acquired Gene Mutations- Certain risk factors probably play a role in causing acquired
mutations, such as:
 Being overweight or obese
 Physical inactivity
 Certain types of diet
 Smoking
 Heavy alcohol use
 Being of older age- much more common after age 50