Faculty of Medicine and Health Sciences

Score sheet for CASE Write-Up

General Surgery (UMCC 3048)

Year 3 MBBS

Student Name : TAN ZHEN HAN

ID no : 17UMB04246

Name of lecturer :

Marks allocated for each section of Case Write up

Chief complaint /5 Discussion of diagnosis & differential /15

diagnosis
History chronologically clear with /20 Basic principles of management and /10
relevant points & important negative follow up
findings

Physical examination findings /20 Discussion on professionalism, ethics, /3

clearly documented patient safety
Summary (Clear and concise) /10 Discussion of communication issues /3

Investigations (Indications, results and /10 Proper use of English language (clear /4
interpretation) & logical)

Total Score /100

Patient Identification

Patient’s initial: Mr. LKH

Age: 73 years old

Ethnic Group: Chinese

Gender: Male

Source of history: Patient Date of clerking: 21/6/2019

Date of admission: 20/6/2019 (Thursday) Date of discharge: -

Chief complaint:

Mr. LKH, 73-year-old gentlemen presents with pain in left iliac fossa for 2 months associated
with symptoms of intestinal obstruction for 2 weeks.

History of presenting illness

Mr. LKH, 73-year- old Chinese gentlemen experience gradual onset of left iliac fossa pain for 2
months. The character of the pain is dull.

2 months ago, Mr. LKH visited a clinic with the complaint of abdominal pain and was suspected
for gastritis. He was given medication for the treatment of gastritis.

The pain worsens 2 weeks ago and it radiates to the right iliac fossa. The severity of the pain is
of score 7/10. The pain is exacerbated after he has his meal. Mr. LKH went to Tung Shin
hospital for check –up and was later referred to Hospital Ampang.

Patient has constipation for 1 week with little bowel output. Bowel output is once a day. Patient
claims that the stool is hard in consistency and normal brown in colour. Patient also claims that
there is no blood or mucus present in the stool. Patient feels bloating in the abdomen for 1 week.
Patient also feels lethargic for 1 week with loss of appetite. Patient also has loss of weight.

Patient has no fever, no nausea, and no vomiting, no signs of jaundice. Patient also has no heart
burn.
Systemic review:

General

The patient has weight loss, loss of appetite, generalized body weakness and lethargic. Patient is
unable to sleep well at night due to the pain. Patient has no fever.

Central Nervous system

The patient has no headache, no dizziness, no seizure.

Cardiovascular system

The patient has no chest pain, no palpitations, no irregular heart beats

Respiratory system

The patient has no shortness of breath, no cough

Gastrointestinal system

As mentioned above.

Genitourinary system

The patient has no dysuria, no haematuria, no genital discharge, normal urine output with normal
urine colour.

Musculoskeletal system

Patient has slight muscle weakness. The patient gait is normal, no joint pain and no muscle pain.

Endocrine system

The patient has no excessive sweating, no heat or cold intolerance.

Past medical history:

Mr. LYK has hypertension, diabetes mellitus. Patient found out that he has these diseases
through regular health checkup at clinic around 10 years ago. Patient has done a CT scan at Tung
Shin Hospital 2 weeks ago.

Past surgical history:

No past surgical history

Drug history:

Patient has taken medication for gastritis treatment from a clinic 2 months ago.

Family history:

There is no family history of malignancy. Patient’s parents passed away due to old age and
patient’s father has diabetes mellitus.

Allergy:

Mr. LYK has no known food or drug allergies.

Social history:

Patient works as a factory worker. Patient is not a smoker and does not drink alcohol. Patient has
regular meal everyday at home and sometimes outside. Patient’s diet includes vegetables. Patient
exercises regular 3 times a week by jogging in the park.
PHYSICAL EXAMINATION AND FINDINGS

Vital signs:

Blood pressure: 171/81mmHg

Pulse rate: 88 bpm

Temperature: 36.8 ˚C

Respiratory rate: 18 br/min

SPO2: 98%

Anthropometric measurements:

Height: 170m

Weight: 70kg

BMI: 24.2(normal)

General Examination

Mr. LYK was conscious and alert. Patient looks slighty lethargic and tired. Patient is of average
height and weight. There is no sign of respiratory distress.

On inspection of the hand, there is a brannula on his right dorsum connected to an intravenous
saline bag. There is no finger clubbing, no leukonychia, no koilonychia, no peripheral cyanosis,
no palmar erythema, no Dupuytren’s contracture, no flapping tremor. Patient has no injection
marks at the arm, no tattoo marks. Capillary refill time is less than 2 seconds. The radial pulse is
of regular rhythm.

Patient has no yellow colouration of sclera, no temporalis muscle wasting, no parotid gland
enlargement. Patient has no central cyanosis, no stomatitis, no aphthous ulcer in the oral cavity.

Patient has no spider nevi in the chest. Patient has no palpable lymph nodes in the axillary and
neck region. There is no pitting edema on both of the legs.
Examination of Abdomen

Positive Findings

There is distension of abdomen with tenderness at the left iliac fossa, left lumbar, right iliac fossa,
umbilical region of the abdomen and palpable mass at right lumbar region and left lumbar.
Shifting dullness is positive. Increased bowel sound and loudly heard.

Inspection

There is no scar present. Shape of the abdomen is rounded. The abdomen is symmetrical on the
right and left side. The abdomen is distended. The abdomen moves with respiration. The
umbilicus is flattened. There is no visible hernia on cough impulse. There is no capet medussa.

Superficial palpation

On superficial palpation of the abdomen, there is tenderness at the left iliac fossa, left lumbar,
right iliac fossa, right lumbar region of the abdomen. Patient felt that the left iliac fossa region is
most painful upon palpation. There is no rigidity and no guarding on light palpation.

Deep palpation

On deep palpation, there is palpable mass at right lumbar region and left lumbar. The
temperature of the mass is normal with the surrounding skin. The mass is not mobile. Liver is not
palpable. Spleen is not palpable. Kidneys are not ballotable.

Percussion

Shifting dullness is positive and fluid thrill test is negative. Normal liver dullness is heard at the
5th intercostal space of the right mid clavicular line. There is resonance on percussion of
Traube’s space, which indicates no signs of spleenomegaly.

Auscultation

There is increase in frequency and loudness of the bowel sounds which shows increased
peristaltic activity. There are no liver and renal bruits.

Digital Rectal Examination (not done by the hospital)

I would like to do Per rectal examination to inspect for blood and mucus present in the stool and
the colour of the stool.
Examination of Central Nervous system

For both upper and lower limbs, there are no scar, no muscle wasting, no involuntary movement,
no fasciculation, no tremor. There is no hypertonia and no hypotonia. Muscle tone is normal. The
power is of grade 5/5 for both upper and lower limbs. Biceps tendon, triceps tendon, supinator
tendon reflex is normal. Knee and archilis reflex is normal. Cranial nerves 1-12 are intact.

Examination of Cardiovascular system

There is no scar at the chest. The chest is symmetrical with no deformity. There is no heave at
the parasternal border. Apex beat which is located at the left 5th intercostal space from the
midclavicular line is not visible. There is no palpable thrill at the tricuspid pulmonnary, aortic,
mitral area of the chest. Heart beat rate is of regular sinus rhythm. S1 and S2 can be heard with
no murmur and no additional sound. There is no sacral edema and no basal crepitations.

Examination of Respiratory system

There is no scar at the chest. . The chest is symmetrical with no deformity. There is no dilated
superficial vein present on the chest. Patient is not on any respiratory ventilator machine with
oxygen supply. Patient is not using any accessory muscles to support his breathing. At the
anterior and posterior of the chest there is no tenderness, tactile fremitus is normal, chest
expansion is symmetrical. There is no tracheal deviation. Resonance can be heard at all area of
the chest anteriorly and posteriorly. Vesicular breath sound with normal vocal resonance can be
heard at all area of the chest anteriorly and posteriorly.

Examination of Gastrointestinal system

As mentioned above

Examination of Musculoskeletal system

For both upper and lower limbs, there are no scar, no swelling, no muscle wasting and no
deformity. Patient gait is normal. There is no tenderness at both of the upper and lower limbs.
Active and passive movements of the limbs are not restricted and the range is normal. Power of
both upper and lower limbs is of grade 5/5.
SUMMARY OF THE CASE

Mr. LKH, 73-year-old gentlemen was admitted to Hospital Ampang on 20/6/2019 with chief
complaint of gradual onset of pain in left iliac fossa for 2 months. The pain worsens for 2 weeks
with constipation and abdominal bloating. The pain also radiates to the right iliac fossa. There is
bowel output once a day with normal stool colour. No blood and no mucus is present in the stool.
Patient has loss of appetite and loss of weight. Patient has no fever, no nausea, no vomiting. On
physical examination, distention of abdomen is present with tenderness at the left iliac fossa, left
lumbar, right iliac fossa, umbilical region of the abdomen. There is 2 separate palpable mass
each at left lumbar and right lumbar region. Shifting dullness is positive. There is increased
bowel sound and is loudly heard.

Provisional Diagnosis

Intestinal Obstruction secondary to Colorectal Carcinoma

Supporting evidence

1. Chronic pain for 2 months

2. Pain at left iliac fossa

3. Constipation

4. Abdominal bloating

5. Abdominal distention

6. Increased frequency of bowel sound

7. Constitutional symptoms (Lethargic and weakness, Loss of appetite, Loss of body weight)

8. Old age and ethnicity (risk factor)

Differential Diagnosis

Acute Diverticulitis

Supporting Evidence Evidence Against

1. Pain and tenderness at the left iliac fossa 1. No fever

2. Constipation

3. Abdominal bloating

4. Abdominal distention

5. Increased frequency of bowel sound

Sigmoid Volvulus

Supporting Evidence Evidence Against

1. Pain and tenderness at the left iliac 1. Constitutional symptoms is present

fossa 2. More common in children

2. Constipation

3. Abdominal bloating

4. Abdominal distention

5. Palpable mass at umbilical region

6. Increased frequency of bowel sound

Revelant Investigations and Indications

Investigation Indication

Full Blood Count - To look for any infection or inflammation from assessing

the white blood cell count

Liver Function Test - To rule out any liver dysfunction

- As a routine and pre-operative investigation

Coagulation profile - As a routine and pre-operative investigation

Renal Profile - To assess and monitor electrolyte imbalance and

dehydration

- As a routine and pre-operative investigation

Blood Grouping & Cross - To determine patient’s ABO blood group, in case of the

Matching need for blood transfusion as patient was having blood

loss, or in surgery.

Radiological/Imaging

Investigation Indication

Computed Tomography - To confirm the diagnosis of colorectal carcinoma and

metastasis

Colonoscopy - To visualize the colon and detect colorectal carcinoma

RESULTS OF INVESTIGATIONS PERFORMED AND INTERPRETATIONS

1. Full blood count

Components Value Reference Range Interpretation

Red blood cells 5.12 (10^6/uL) 4.53 - 5.95 Normal
Haemoglobin 10.6 (g/dL) 13.5- 17.4 Low
Haematocrit 36.5 (%) 40.1 - 50.6 Low
Mean cell volume 71.3 (fL) 80.6 - 95.5 Low
Mean cell haemoglobin 20.7 (pg) 26.9 - 32.3 Low
Mean cell haemoglobin 29.0 (g/dL) 31.9 - 35.3 Normal
concentration
Platelet 269 (K/uL) 142 – 350 Normal
Red cell distribution 19.6 (%) 12.0 - 14.8 Normal
width
White blood cells 11.4 (K/uL) 4.1 - 11.4 High

Comments:

The decreased in red blood cell might be an indicative of mild anaemia.

2. White blood cell differential count

Components Value Reference Range Interpretation

Absolute neutrophil 8.2 (K/uL) 3.9 - 7.1 High
Absolute lymphocyte 1.9 (K/uL) 1.8 - 4.8 Normal
Absolute monocyte 0.9 (K/uL) 0.4 - 1.1 Normal
Absolute eosinophil 0.4 (K/uL) 0.0 - 0.8 Normal
Absolute basophil 0.1 (K/uL) 0.0 - 0.1 Normal
Percentage of 71.9 (%) 30.0 - 65.0 High
neutrophil
Percentage of 16.4 (%) 40.0 - 70.0 Low
lymphocyte
Percentage of 7.5 (%) 2.0 - 10.0 Normal
monocyte
Percentage of 3.6 (%) 1.0 - 4.0 Normal
eosinophil
Percentage of basophil 0.6 (%) 0.5 - 1.0 Normal

Comments:

There is slight increase in neutrophil count.

 3. Renal profile

Components Value Reference range Interpretation

Urea 4.80 mmol/L 2.76 - 8.07 Normal
Sodium 137 mmol/L 136 – 146 Normal
Potassium 4.1 mmol/L 3.4 - 4.5 Normal
Chloride 100 mmol/L 98 - 107 Normal
Creatinine 70 umol/L 44 - 80 Normal

Comments:

The result of Renal Profile is normal.

4. Liver function test

Components Value Reference range Interpretation

Bilirubin, Total 8.50 umol/L 0.00 - 21.00 Normal
Protein, Total 67.69 g/L 66 - 87 Normal
Alkaline Phosphatase 128 u/L 40 - 129 Normal
Albumin 40.9 g/L 35 - 52 Normal
Globulin 26 g/L 20 - 35 Normal
Alkaline 22 u/L 0 – 41 Normal
Transaminase

Comments:

The result of Liver function test is normal.

5. Coagulation profile

Components Value Reference range Interpretation

Activated Partial 27.8 sec 30 – 44 Normal
Thromboplastin Time
Prothrombin Time >12.9 sec 11.3-13.8 Normal
International 1.06 -
Normalised Ratio

Comments:

The result of coagulation profile is normal.

 6. Computed Tomography of the Abdomen

Findings:

Ascending colon carcinoma with metastasis to the liver

Discussion of Provisional and Differential Diagnosis

Mr. LKH, 73-year-old gentlemen was admitted to Hospital Ampang on 20/6/2019 with chief
complaint of gradual onset of pain in left iliac fossa for 2 months. The pain worsens for 2 weeks
with constipation and abdominal bloating. The pain also radiates to the right iliac fossa. There is
bowel output once a day with normal stool colour. No blood and no mucus is present in the stool.
Patient has loss of appetite and loss of weight. Patient has no fever, no nausea, no vomiting. On
physical examination, distention of abdomen is present with tenderness at the left iliac fossa, left
lumbar, right iliac fossa, umbilical region of the abdomen. There is 2 separate palpable mass
each at left lumbar and right lumbar region. Shifting dullness is positive. There is increased
bowel sound and is loudly heard. These clinical features suggest of symptoms of intestinal
obstruction with carcinoma of colon.

Intestinal obstruction occurs when there is a partial or complete block in the gastrointestinal tract
that leads to the stasis of the faeces. Intestinal obstruction can be classified pathologically into
functional intestinal obstruction and mechanical intestinal obstruction. A disease of functional
intestinal obstruction is paralytic ileus. The distinctive clinical feature for paralytic ileus is the
absence of bowel sounds in auscultation. As Mr. LKH has increased frequency and loudness of
bowel sound in auscultation, Mr. LKH is more likely to have mechanical intestinal obstruction
therefore paralytic ileus is not considered as one of my differential diagnosis.

The cardinal clinical features of acute intestinal obstruction are abdominal pain, distention,
vomiting, and constipation. Usually in small bowel obstruction, vomiting will occurs early
followed by minimal distention, pain, and constipation. For large bowel obstruction vomiting is
the later feature as distention or constipation is the early symptoms with abdominal pain. In Mr.
LKH history of presenting illness, the symptom of vomiting is not present, therefore Mr. LKH is
more likely to have large bowel obstruction. Intussusception and volvulus are the most common
disease of intestinal obstruction. The typical presentation of intussusception is redcurrant jelly
stool. As Mr. LKH’s stool is normal in colour with no blood and mucus present and on physical
examination, palpable mass that was detected with increased of frequency and loudness of bowel
sound, sigmoid volvulus is considered as one of my differential diagnosis.

Colorectal carcinoma is a lethal disease as the peak incidence is usually related to elderly people.
Most large bowel cancers arise from the left colon, notably the rectum (38%), sigmoid (21%),
and descending colon (4%). Cancer of the caecum (12%) and ascending colon (5%) are less
common. Cancer of the transverse colon (5.5%), flexures (2-3%) and appendix (0.5%) are
uncommon. The four common macroscopic varieties of colon carcinoma is annular, tubular,
ulcer, cauliflower. Microscopically, the neoplasm of colon carcinoma is a columnar cell
adenocarcinoma. It may originate from benign polyps and then later proceeds to malignant
infiltration that destroys the benign architecture.
Carcinoma of the colon commonly occurs in patients that is 50 years old and above and is most
commonly occur in patient that is 80 years old. Family history from first degree relatives is
important to include malignancy in the diagnosis. Tumours of colon normally presents with
change of bowel habit or rectal bleeding and later will present with iron deficiency aneamia. The
annular macroscopic pathology of colon carcinoma will present with symptoms of intestinal
obstruction as it forms like a stricture. Mr. LKH, an elderly patient, with constitutional symptoms
of malignancy, and chronic abdominal pain for 2 months which later worsens with symptoms of
intestinal obstruction for 1 week highly suggest colon carcinoma as my provisional diagnosis.

Colonic cancer can spread locally, via lymphatics, bloodstream, or transceolomically across the
peritoneal cavity. The computed tomography scan done on Mr. LKH shows the he has colon
cancer that metastasize to the liver. Haematogenous spread is the most commonly to the liver via
the portal vein from the colon. One-third of patients will have liver metastasis at the time of
diagnosis and half of the patients will eventually develop it at some point. In Mr. LKH’s case,
computed tomography scan is done before endoscopy. The results of the CT scan not only show
ascending colon carcinoma but also metastasis of the liver.

Another differential diagnosis that has been considered is acute diverticulitis. Diverticulitis, is
characterized by inflammation of abnormal pouches called diverticula, which can develop in the
wall of the large intestine. An inflammed diverticula can cause narrowing of the bowel, which
leads to intestinal obstruction as a result of complication of diverticulitis. Diverticulitis typically
presents with left iliac fossa pain of sudden onset. Mr. LKH presents with left iliac fossa pain of
gradual onset and symptoms of intestinal obstruction suggest diverticulitis, however Mr. LKH
does not have fever and there is no significant increase white blood cell differential count.

Final Diagnosis

Ascending colon carcinoma with liver metastasis.

BASIC PRINCIPLES OF MANAGEMENT AND FOLLOW UP

Preoperative Preparation

1. Bowel preparation
- 3 days soft diet
-nil by mouth 24 hours before operation

2. Intravenous prophylatic antibiotic

-reduce risk of surgical site infection

3. Stoma site discussion

-discuss with stoma care nursing specialist

Definitive treatment

1. Right hemicolectomy
-remove carcinoma completely with clear margins
-resect adjacent draining lymph nodes
-reconstruct the bowel (to achieve intestinal continuity)
2. Chemotherapy
-to treat metastasis of the liver

Follow up

1. Colonoscopy after 1 year of operation

-detect risk of recurrence

2. Computed tomography scan

-to detect any further metastasis
PATIENT SAFETY, PROFESSIONALISM, COMMUNICATION AND ETHICAL
ISSUES

Discussion of Communication Issues

Before clerking the patient and asking for patient history, I will build a strong rapport with the

patient by smiling, and greeting them. I will introduce myself and ask for permission before proceeding.

In any cases of asking sensitive questions, I will ask for permission beforehand and ensure that their

information obtained from clerking will be strictly confidential. There is language barrier between and the

patient as the patient can converse in Mandarin. This patient is unable to tell me clearly where the

location of the pain in his abdomen is. As knowing the exact location of the pain is crucial for me, I told

the patient to show me the pain region by pointing it towards the part of his abdomen with his finger.

Before carrying out the physical examination on the patient, I sanitized my hand with alcohol rub

to prevent any infectious transmission to the patient or from the patient. I therefore proceed to close the

curtain to protect patient’s privacy. I will ask for the patient’s consent for removing his shirt to expose the

abdomen. During the examination of the patient’s abdomen, I will ensure that the patient’s chest is

covered with his shirt and not exposed. Before palpating the abdomen, I will remind the patient to tell me

when the pain is felt to prevent me from doing further harm towards the patient.

References:

1. Williams, N., Bulstrode, C., O’Connell, P., Bailey, H. and Love, R. (2008). Bailey & Love’s Short
Practice of Surgery. London: Hodder Arnold.

2. Norman L. Browse. John Black. Kevin G. Burnand. William E. G. Thomas. Chapter 15. The
Abdomen. Browse’s Introduction to The Symtoms and Signs of Surgical Disease. 5th edition.