อาการวิทยา
(SYMPTOMATOLOGY)
Case Study: Part 2
Introduction to Clinical Medicine
วิชาบทนําเวชศาสตร์คลินิก (RAID 303)
นักศึกษาแพทย์ชั้นปีที่ 3
คณะแพทยศาสตร์โรงพยาบาลรามาธิบดี มหาวิทยาลัยมหิดล
สารบัญ
หน้า Jaundice case 1.....................................................................4 Jaundice case 2.....................................................................6 Melena.....................................................................................8 Hematemesis case 2.............................................................9 Hematochezia case 3..........................................................10 Hematochezia case 4..........................................................12
PART 2 Case Study
Jaundice case 1
The patient is a 21-year-old Thai man who came back a few weeks from having his vacation on trekking along the northern border between Thailand and Myanmar. He has had jaundice, high grade fever with chill for about one week. His appetite is absent with nausea and vomiting. His urine color turns dark since the occurrence of jaundice. He does not have abdominal pain and his bowel motion is normal. His past history is not significant. He never receives blood transfusion and does not have chronic medical illnesses. During his illness, he has taken only medication to relieve fever (acetaminophen (500 mg) 2 tabs prn for fever every 6 hours). He denies regular alcoholic drinking, smoking, herbal medication and intravenous drug use. His family history is negative for significant diseases. Physical examinations Vital signs T 40oC, PR 110/min regular, RR 22/min, BP 120/70 mmHg General A young man, slightly distress, mild jaundice, appearance slightly pale, no stigmata of chronic liver disease Skin No lesion HEENT Normal Lymph nodes Not palpable
4 | Symptomatology part 2
PART 2 Physical examinations CVS Jugular venous pressure (JVP): not raised Apex at 5th ICS, mid-clavicular line(MCL) No heaving, no thrill Normal S1, S2, no murmur RS Normal chest movement, equal bilaterally Normal percussion Abdomen Soft, not tender, no abnormal mass, no ascites Liver – 3 cm below RCM (soft with mild tenderness) Spleen – 2 cm below LCM PR Normal
Question 1. What are the main problems of this patient? 2. Analyze the information from history and physical examination, and give your differential diagnosis.
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PART 2 Case Study
Jaundice case 2
The patient is a 67-year-old Chinese man who has had jaundice for one month. Besides progressive jaundice, he has constant abdominal pain at the epigastric area occurring at the same time. During his illness, he has never had fever but lost his appetite. He has lost 5 kg in one month. He has had pruritus and clay-colored stool for a few weeks. There’s no dyspnea, headache, bowel habit change or vomiting. He has had diabetes mellitus and hypertension for 10 years, and taken medications regularly. He has never been admitted to a hospital. He denies alcoholic drinking, herbal medicine taking, intravenous drug use, blood transfusion and raw fish eating. He lives in Bangkok with his wife and his two children. All of his relatives are in good health.
Physical examinations Vital signs T 37.2oC, PR 84/min regular, RR 18/min, BP 150/90 mmHg General An elderly man, look cachectic, not in distress, appearance marked jaundice, not pale, no stigmata of chronic liver disease Skin Generalized greenish hue with excoriation HEENT Normal
6 | Symptomatology part 2
PART 2 Physical examinations CVS Jugular venous pressure (JVP): not raised Apex at 5th ICS, mid-clavicular line(MCL) No heaving, no thrill Normal S1, S2, no murmur RS Normal chest movement, equal bilaterally Normal percussion Normal breath sounds, no adventitious sounds Abdomen Soft, not tender, no abnormal mass Liver and spleen – not palpable No ascites PR Clay-colored stool with rectal shelf
Question 3. What are the main problems of this patient? 4. Analyze the information from history and physical examination, and give your differential diagnosis.
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PART 2
Melena A 76-year-old man presents with black, tarry stools and epigastric pain for 2 days. He did feel a little light-headed from time to time, and on the day of admission he actually passed out while again passing considerable black stool. He is brought to the hospital several hours after fainting. He has been in excellent health and had no previous serious illnesses, or operations. He is not taking medications regularly. About once a month he takes 2 aspirins for a headache and an occasional antacid for indigestion. He smokes 3 packs of cigarettes per week, drinks a bottle of beer every few days, and has coffee once daily. On arrival, he feels weak and looks pale, but has no other complaints. Physical examination reveals T 37oC, PR 120/min, RR 16/min, BP 100/60 mm/Hg, pallor, mild tenderness at epigastrium, no abdominal mass and no hepatomegaly. Digital rectal examination shows black stool.
Study this symptom among yourself, and answer the following questions: 1. How to approach? 2. How to determine the site of gastrointestinal (GI) bleeding (upper or lower GI tract)? 3. Give the differential diagnosis of the causes of GI bleeding in this patient?
8 | Symptomatology part 2
PART 2
Hematemesis
case 2
A 50-year-old man presents with vomiting out 200 ml of blood 3 hours ago. He denies any abdominal pain but feels light headedness. He is previously healthy with no know underlying disease. He drinks alcohol daily for more than 20 years. He denies smoking or regular analgesics usage. He has no history of operation, blood transfusion or intravenous drug use. There is no family history of liver disease such as cirrhosis or liver cancer. Physical examinations Vital signs T 37oC, PR 100/min, RR 20/min, BP (supine) 90/60 mmHg, BP (sitting upright) 80/50 mmHg General pale with mild icteric sclerae, palmar erythema, appearance spider nevi on chest wall, mild parotid gland enlargement Heart tachycardia, no murmur Lungs clear Abdomen Liver: 2 cm below right costal margin (span 13 cm by percussion) Spleen: dullness on percussion Extremities: no edema
Questions: 1. What is/are problems of this patient? 2. What could be the cause of hematemesis in this patient?
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PART 2
Hematochezia
case 3
A 76-year-old woman presents with bloody stool for 3 days. The patient has noticed fresh blood with bowel movement 5-6 times a day. The blood was bright red but sometime of darker color. She denies abdominal pain and fever, but feels light headedness and palpitation. She has had hypertension and diabetes for 10 years. She also had right sided weakness from ischemic stroke and serum creatinine of 3.5 mg/dl 2 years ago. She has chronic kidney disease. Her current medications are insulin, antihypertensive and aspirin. She has no history of previous operation, blood transfusion or intravenous drug use. She denies smoking or alcohol consumption. There is no family history of liver disease such as cirrhosis or liver cancer. Physical examinations Vital signs T 37oC, HR 110 /min, RR 20 /min, BP (supine) 90/60 mmHg, BP (sitting upright) 80/50 mmHg General mild pallor, fully conscious appearance Heart tachycardia, no murmur Lungs clear bilaterally Abdomen not distended, normal bowel sound, soft liver and spleen – not palpable shifting dullness – negative PR maroon red blood Extremities no edema
10 | Symptomatology part 2
PART 2 Questions: 1. What is/are problems of this patient? 2. What could be the cause of hematemesis in this patient?
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PART 2
Hematochezia
case 4
A 62-year-old man presents with severe bleeding per rectum for one day. He denies abdominal pain, bowel habit change, nausea and vomiting. His medical history is significant only for hypercholesteremia. He has no history of surgery, use of medications, allergy, or recent travel; his family history is similarly unremarkable. He smokes occasionally but does not drink alcohol or use drugs. Physical examination shows the patient to be hypotensive, with a blood pressure of 80/50 mmHg. Body temperature is 36.2 oC, pulse rate is 108 beats/min, and respiratory rate is 18 breaths/min. He appears pale and weak, with a dry oral mucosa. His abdomen is soft, nontender, and nondistended; bowel sounds are normal. Rectal examination and proctoscopy reveal red blood but no hemorrhoids or masses. The rest of the examination is unremarkable.
Study this symptom among yourself, and answer the following questions: 1. How to approach? 2. How to determine the site of gastrointestinal (GI) bleeding (upper or lower GI tract)? 3. Give the differential diagnosis of the causes of GI bleeding in this patient
12 | Symptomatology part 2
PART 2
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