อาการวิทยา
(SYMPTOMATOLOGY)
Case Study: Part 2
Introduction to Clinical Medicine
วิชาบทนําเวชศาสตร์คลินิก (RAID 303) นักศึกษาแพทย์ชั้นปีที่ 3
คณะแพทยศาสตร์โรงพยาบาลรามาธิบดี มหาวิทยาลัยมหิดล
สารบัญ
หน้า Diarrhea case 1.....................................................................4 Diarrhea case 2.....................................................................6 Vomiting case 1.....................................................................8 Vomiting case 2...................................................................10
PART 2
Diarrhea
case 1
History Patient profile: A 10-year-old male student from Bangkok Chief complaint: Passing watery stools for 6 hours. Present illness: At 6 pm last night after dinner, he started to feel sick and vomited twice. The vomitus contained food and yellowish gastric content. He has also had intermittent crampy abdominal pain since the beginning of his illness. The pain is generalized and each episode lasts 30-40 minutes. Since midnight he has been passing large amount of 4 loose and watery stools. There has been no mucous or blood in his stools. He has fried rice with crab meat as his lunch at school yesterday. Few of his friends have also experienced the same symptoms. Past medical illness: Previously healthy.
4 | Symptomatology part 2
PART 2 Physical examinations Vital signs T 37.5oC, PR 110/min, RR 20/min, BP 90/60 mmHg General Look weak but alert appearance HEENT Dry lips, no sunken eyeballs Heart & lungs Normal Abdomen Not distended, active bowel sound No tenderness, no guarding, no abnormal mass Skin Normal skin turgor
Instruction 1. Summarize key information from the history and physical examination. 2. Use these information to refine your hypotheses.
Symptomatology part 2 | 5
PART 2
Diarrhea
case 2
History Patient profile: A 2-year-old girl from Bangkok Chief complaint: Passing mucous bloody stools for 3 hours Present illness: Twenty four hours prior to this hospital visit, a previously healthy 2-year-old girl developed high fever and passed 4 large watery stools. During the past 3 hours, she has cried intermittently and passed 4-5 mucous bloody stools. She seemed to be thirsty and had small amount of urine. Feeding history: Three meals and 4 bottles of milk per day. Family history: No other family members currently experience the same symptoms. Grandmother is her primary caretaker.
6 | Symptomatology part 2
PART 2 Physical examinations Vital signs T 40oC, PR 120/min, RR 28/min, BP 90/60 mmHg General Alert & active appearance HEENT Dry lips & mucous membrane, mild sunken eyeballs Heart Tachycardia, lungs: clear Abdomen Not distended, active bowel sound, soft, not tender, no palpable mass
Instruction 1. Summarize key information from the history and physical examination. 2. Use these information to refine your hypotheses.
Symptomatology part 2 | 7
PART 2
Vomiting case 1
History Patient profile: A single female secretary from Bangkok Chief complaint: Protracted vomiting for 36 hours Present illness: Vomiting started 2 days ago after dinner. At the beginning, the vomitus contained food and gastric content which was yellowish and tasted sourly. During the past 12 hours, the vomiting was projectile, progressive and occurred even after drinking water. The vomitus was greenish and tasted bitterly. She has also experienced intermittent and generalized colicky abdominal pain. There has been no defecation for 24 hours. Past medical history: Previously healthy Appendectomy at the age of 20. The diagnosis was delayed and her appendix ruptured before the operation.
8 | Symptomatology part 2
PART 2 Physical examinations Vital signs T 37.3oC, PR 108/min, RR 20/min, BP 100/60 mmHg General Healthy looking, in acute distress during the epiappearance sode of abdominal pain. HEENT Dry lips Heart & lungs Normal Abdomen Slightly distended, surgical scar at RLQ. Active bowel sound Generalized mild tenderness, no rebound tenderness Neurological No focal neurological dysfunction, exam normal eyegrounds.
Instruction 1. Summarize key information obtained from the history and physical examination. 2. Use these information to refine your hypotheses.
Symptomatology part 2 | 9
PART 2
Vomiting case 2
History Patient profile: A 2-month-old male infant from Bangkok Chief complaint: Recurrent vomiting since birth Present illness: He was born normally with birth weight of 3,000 grams and has been exclusively breast-fed. Since birth he has had 3-4 episodes of vomiting per day, 5-10 minutes after feeding. The vomitus contains milk, no bile and no blood. It is not progressive.
10 | Symptomatology part 2
PART 2 Physical examinations Vital signs T 37oC, HR 120/min, RR 30/min General Active, not pale, BW 5,000 g appearance (normal weight gain) HEENT HC 37 cm; anterior fontanelle 3 x 3 cm, no sunken eyeballs Heart & lungs no abnormal findings Abdomen not distended, normal bowel sound, soft, no palpable mass
Instruction 1. Summarize key information obtained from the history and physical examination. 2. Use these information to refine your hypotheses.
Symptomatology part 2 |11