case write up surgical gastric carcinoma
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Name: D M AAge: 59 years oldGender: MaleRace: MalayOccupation: PensionerAddress: Taman Haji Ahmad 3, Kuantan, Pahang.Date of admission: 23th March 2015Date of Clerking: 26th March 2015
CHIEF COMPLAINTPatient presented with 5 months history of progressive abdominal pain associated with per rectal bleeding and early satiety for 1 month duration.
HISTORY OF CHIEF COMPLAINTPatient was apparently well until 5 months ago, when he experienced abdominal pain that is generalized as he unable to pinpoint the location of the pain. The pain was sudden in onset, colicky in nature and gradually increasing in severity. However, he still able to tolerate the pain and it did not affect his daily activities. Around 3 months after the onset of the symptom, the pain which is initially generalized had radiated to the epigastric region. The pain had been burning in nature and aggravated by food ingestion especially spicy and salty food. He then went to a nearby Klinik Kesihatan and was prescribed with a medication. The symptom was noted to be relieved by the medication. There was no episode of nausea or vomiting, water brash or heartburn sensation.Around 1 month prior to admission, patient developed a new onset of passing out painless per-rectal bleeding in a form of black-tarry stool. It was dark and mixed with his stools. He noticed that his stool smells awfully disturbing and become stickier. The frequency of bowel output however not changes as patient usually passes motion around once in two days. After passing out the black-tarry stool, he experienced palpitation, dizziness and syncope attack in which he needed to lie down to prevent from fall. There is no however episode of vomiting out blood, yellowish discoloration of the eye and skin, and no right hypochondriac pain. He also denied any episodes of epistaxis, bleeding gum or easily bruising. There was no associated tenesmus and passing out mucus.
Since the beginning of the onset of the per-rectal bleeding, he never went to seek for medical attention as he claimed that in between the per-rectal bleeding, he was feeling well. Until after a month of the onset of per-rectal bleeding that he noticed that he had some weight loss by the reduction in his pants size that is also associated with loss in appetite. The amount of food intake has also reduced as he felt easily full. This condition was also noticed by his daughter who brought him to the hospital and during admission, several investigations had been done to clarify the cause of his per-rectal bleeding.
SkinSkin was normal with no change in the color and contour. There was also no itchiness noted.
HeadThere were no swellings or any injury of the face.
EyesThere was pallor, but no jaundice, no redness or any discharge from the eyes.
EarsThere was no discharge or hearing impairment.
NoseThere was no discharged, nose block, bleeding or odor from the nose.
Mouth and throatThere was no any odor.
NeckThe neck region was normal. There were no any swellings or stiffness.
Respiratory systemThere were no episodes of cough, breathlessness, noisy breathing or hemoptysis
Cardiovascular systemThere was palpitation, but no dyspnea, orthopnea, cyanosis, or chest pain.
Hepatobiliary systemThe patient has no jaundice.
Hemopoietic systemThis system was intact with no jaundice or bleeding tendency
Neuromuscular systemThis system was intact with no swelling and weakness of muscles, bones and joints. There were also no abnormality of movements and coordination.
Urologic systemPatient had episodes of gradually increasing in difficulty of passing urine but with no episode of dysuria or hematuria.
PAST MEDICAL HISTORYHe is a known case of diabetes mellitus which is diagnosed 10 years ago. Currently he is on single type of oral hypoglycemic agent. Otherwise, he is not known to have hypertension, ischemic heart disease or malignancy. There is also no history of blood transfusion.PAST SURGICAL HISTORYHe has no previous history of hospitalization. He also never underwent any form of surgical treatment or intervention.
DRUG AND ALLERGY HISTORYFor the past 10 years, he had been taking his oral hypoglycemic agent regularly. For the past 1 year, he had been taking commercial health supplement in a form of soluble powder that is taking daily. Otherwise, there is no history of chronic ingestion of non-steroidal anti-inflammatory drugs (NSAIDs) for any reason. He has no known allergies towards drugs or foods.
FAMILY HISTORYThere is no family history of chronic disease such as diabetes mellitus, hypertension and ischemic heart diseases running in the family. There is also no known family history of gastrointestinal malignancy.
SOCIAL HISTORYHe is a pensioner who previously worked as an owner of a restaurant. Currently the restaurant is run by his son. He lives in a single storey-house at Taman Haji Ahmad with his wife and his 4 children. He is a heavy smoker that smokes around 2 packs of cigarettes per day. Otherwise, there is no history of chronic alcohol consumption, tattooing or high risk behaviors.
PHYSICAL EXAMINATIONGENERALPatient was lying comfortably in supine position. He was alert, conscious and oriented to time, place and person. He was not in pain or in respiratory distress. There was a peripheral cannulation located at the dorsum of his right hand with no active infusion. He looked pale but no jaundice noted. There was also wasting over the temporalis muscle. There was also evidence of impaired nutritional status from wasting of both thenar and hypothenar muscle. The hydration status of the patient was however good.
There were no stigmata of liver disease noted such as flapping tremors, loss of axillary hair and spider nevi. There were also no bruises over the upper and lower limb. There was no injection marks and tattoo noted. There was also no pedal edema.
VITAL SIGNSBlood pressure: 126/88 mmHgPulse rate: 88 beats/ minute, good volume and regular rhythmTemperature: 37oCRespiratory rate: 16 breathe/ minute
PERABDOMINAL EXAMINATIONThe abdomen was not distended. There were no abnormal skin changes, scars or dilated veins. The cough impulse was negative. The abdomen was soft and non-tender. There was a vague mass located at the epigastric area that didnt move with respiration. The mass was not pulsating. The mass was hard and with irregular margin. The surface was unappreciable. There was dullness over the mass with percussion, Succussion splash test was negative. Otherwise there was no bruit heard over the mass. Otherwise there was no hepatomegaly and splenomegaly. Both kidneys were not ballotable. There is negative shifting dullness. The bowel sound was present. The left supraclavicular lymph node (Virchows gland) was not palpable.
DIGITAL RECTAL EXAMINATIONOn inspection, there was no skin rashes, excoriation, mass, scars, fistula or fissures. However, a small skin tag was seen at 6 oclock position. There was no fecal soiling, blood or mucus discharge.Upon digitation, the tone of the sphincter was present and normal. Prostate gland was enlarged but symmetrical. The surface is smooth and firm to consistency. The median sulcus was palpable. Otherwise the rectum was empty with no masses felt. Upon removal the finger, there was dark brownish feculent stain over the finger.
RESPIRATORY EXAMINATIONThe chest was normal in shape with no scars of dilated veins. The chest expansion was equal bilaterally. There is also equal vocal fremitus and both lungs field were resonance on percussion. There is equal air entry with no added sounds was heard such as rhonchi or crepitation.
CARDIOVASCULAR EXAMINATIONThe apex beat was palpable at left 5th intercostal space, midclavicular line. There are no thrills or parasternal heave noted. Both normal heart sounds were heard with no murmurs.
NEUROLOGICAL EXAMINATIONThere was normal motor function of both upper and lower limb with muscle power of 5 on all limbs. The sensory parts were also normal with intact cranial nerve function.
59 years old, Malay pensioner, a heavy smoker, with underlying 10 years history of diabetes mellitus currently on treatment, presented with history of passing out black-tarry stool for 1 month, associated with anemic symptoms, loss of weight and loss of appetite, and epigastric abdominal pain. There are no symptoms of metastasis. There is no family history of malignancy. Physical examination revealed vague and hard epigastric mass that is not moving with respiration.
PROVISIONAL DIAGNOSISCarcinoma of the Stomach
Reasons favoring: First is his age group. Incidence of carcinoma of the stomach peaks around the age of fifty to seventy. He had central pain initially and become more localized to epigastric pain, which is the characteristic of the pain change from colicky to burning pain. The pain also exacerbated by eating. The pain was also not periodic, in comparison to peptic ulcers. Loss of appetite and loss of weight is the cardinal symptom of stomach cancer and usually occurs long before any other symptoms arise. He also has symptoms of upper gastrointestinal bleeding which is black tarry stool and symptoms of anemia. He is also a smoker which is one of the risks to get stomach carcinoma. There is also vague mass palpable at the epigastric region.
Reasons against: he has no symptoms of intestinal obstruction, no altered bowel habit and he had a vague history of gastric ulcer.
1. Peptic Ulcer
Reasons favoring: Firstly is his age group. Secondly, gastric ulcers usually cause loss of weight since patients are afraid to eat and the pain is associated with food intake. Epigastric pain, vomiting and water brash are also pres