อาการวิทยา
(SYMPTOMATOLOGY)
Case Study: Part 2
Introduction to Clinical Medicine
วิชาบทนําเวชศาสตร์คลินิก (RAID 303)
นักศึกษาแพทย์ชั้นปีที่ 3
คณะแพทยศาสตร์โรงพยาบาลรามาธิบดี มหาวิทยาลัยมหิดล
สารบัญ
หน้า Abdominal Pain case 1 Part 2.................................................................................4 Part 3.................................................................................5 Abdominal Pain case 2 Part 2.................................................................................6 Part 3.................................................................................7 Abdominal Swelling case 1.................................................8 Abdominal Swelling case 2................................................10
PART 2
Abdominal Pain case 1
“A 45-year-old woman presents with upper abdominal pain for 3 hours� Her pain started at about 9 pm, 3 hours after dinner. Initially the pain was at epigastric region but moved to right upper quadrant and was referred below the angle of the right scapula. With lying motionless, in a curled-up posture, and local heat applied, she felt like her pain was a little bit relieved. She also experienced nausea and urge to defecation but nothing was out. During the last 3 years she had multiple attacks of epigastric pain, usually late at night, lasting about 1 to 2 hours then completely resolved. This time the pain was more severe and longer lasting. She had no fever, no diarrhea, no vomiting. She was previously in good health. Her parents had diabetic. Study this information among yourselves, and answer the following questions:
4. What are your differential diagnoses?
5. What would you look for in the physical examination to help you make the diagnosis?
4 | Symptomatology part 2
PART 3
Abdominal Pain case 1
“A 45-year-old woman presents with upper abdominal pain for 3 hours� Her pain started at about 9 pm, 3 hours after dinner. Initially the pain was at epigastric region but moved to right upper quadrant and was referred below the angle of the right scapula. With lying motionless, in a curled-up posture, and local heat applied, she felt like her pain was a little bit relieved. She also experienced nausea and urge to defecation but nothing was out. During the last 3 years she had multiple attacks of epigastric pain, usually late at night, lasting about 1 to 2 hours then completely resolved. This time the pain was more severe and longer lasting. She had no fever, no diarrhea, no vomiting. She was previously in good health. Her parents had diabetic. Physical examination: temp 38oC, P 96 beats/min, RR 20 /min, no jaundice soft abdomen, normal bowel sound, no hepatomegaly impalpable gallbladder, Murphy’s sign positive Answer the question:
6. What is the most likely diagnosis?
Symptomatology part 3 | 5
PART 2
Abdominal Pain case 2
The patient is a known case of hypertension, diabetes mellitus and constipation for 10 years. Seven days ago, he started to have abdominal pain at periumbilicus and lower abdomen. The features of the abdominal pain are cramping and insidious onset. The severity of the pain increases gradually during this time. Although his appetite is maintain, he vomits yellowish food content several hours after having meal. Since yesterday, he has not had bowel movement and has not pass gas. He feels distressed from abdominal distension. Study this information among yourselves, and answer the following questions:
4. What are your differential diagnoses?
5. What would you look for in the physical examination to help you make the diagnosis?
6 | Symptomatology part 2
PART 3
Abdominal Pain case 2
The patient is a known case of hypertension, diabetes mellitus and constipation for 10 years. Seven days ago, he started to have abdominal pain at periumbilicus and lower abdominal pain. The features of the abdominal pain are cramping and insidious onset. The severity of the pain increases gradually during this time. Although his appetite is maintain, he vomited partially digested, yellowish food content several hours after having meal. Since yesterday, he did not have bowel movement and has not passed gas. He feels distressed from abdominal distension. Physical examination: T 37oC, PR 70 beats/min, RR 22/min, mild pallor, no palpable lymph nodes. Heart and lungs are normal. Abdomen: generalized marked distension, visible peristalsis, increased bowel sound, soft, not tender, no guarding and no rebound tenderness. Per-rectum examination:empty rectum, no rectal shelf. Answer the question:
6. What is the most likely diagnosis?
Symptomatology part 3 | 7
PART 2 Case Study
Abdominal Swelling case 1
“A 40-year-old lady presents with abdominal swelling noticed for 4 weeks� She works as a teacher, unmarried, and has been healthy all along with no major illness or hospitalization. Four weeks ago, she started to notice the increase of her waistline size so that she had difficulty with her skirt and trousers. She also gained 2 kg. in weight. First, she reduced her diet to lose some weight but her waistline and weight still gradually increase. She becomes worried and comes to see you as her family doctor. She has no other symptoms: no fever, no belching, no vomiting, no abdominal pain, only slight discomfort felt in her lower abdomen. Her bowel habit has not changed with daily bowel movement of normal looking stool. Her menstrual period has been irregular for some time and the last menstrual period (LMP) was 6 weeks ago. She never has sexual activity. Urination is more frequent for the past few weeks both day and night, with no pain or discomfort when passing urine. The appearance of urine is normal. She denies any alcoholic consumption or smoking.
8 | Symptomatology part 2
PART 2 PE T 37oC , P 70/min regular, R 16/min, BP 120/70 mmHg in supine position GA A normal-built lady, not pale,not icteric, no spider nevi HEENT normal oral mucosa, no lesions no thyroid enlargement Heart apex at 5th ICS, just medial to MCL, no heave, normal S1, S2, no murmur Lungs clear Abdomen distended, no striae, no superficial vein dilatation fluid thrill – positive on percussion in supine position : dullness at mid abdomen and more tympany at periphery on both sides of abdomen with no shifting of dullness. liver span 10 cm. Extremities no edema CNS unremarkable
Question 3. What is the main problem of this patient?
4. Analyse the data from history and physical findings and give your interpretation regarding the pathology in her abdomen.
5. What is your differential diagnosis?
Symptomatology part 2 | 9
PART 2 Case Study
Abdominal Swelling case 2
The patient is a previously healthy lady who works with a government office in Bangkok. Since 3 months prior to this visit, she has noticed the enlargement of her abdomen. Beside the distended abdomen, she does not feel anything wrong. Her weight has been stable. Her appetite is normal. She does not have fever, and nor does she have constitutional symptoms. Her last menstruation was 5 years ago. She denies alcohol drinking, smoking, and has never received blood transfusion. She has physical examination annually and never showed evidence of viral hepatitis B or C infection. Her familial history is not significant. PE T 37oC, PR 70/min regular, RR 16/min, BP 120/70 mmHg GA a middle age lady, not pale, no jaundice, no stigmata of chronic liver disease Lymph nodes supraclavicular nodes – palpable (with the maximal node diameter of 3 cm) Heart apex at 5th ICS, just medial to MCL; normal S1, S2, no murmur Lungs clear Abdomen generalized distension, no striae, no superficial vein dilation Fluid thrill and shifting dullness – positive, liver and spleen – not palpable
10 | Symptomatology part 2
PART 2 Per-rectum rectal shelf – palpable examination Extremities no edema
Question
3. What is the main problem of this patient?
4. Analyse the data from history and physical findings and give your interpretation regarding the pathology in her abdomen.
5. What is your differential diagnosis?
Symptomatology part 2 |11