University of Santo Tomas Espa

NURSING HISTORY

GP is 67 year old male patient. He is a Filipino and a Roman Catholic. He was born on December 9, 1945 in Nueva Ecija. He is married and has three children. He is currently as resident of General Luna, Cabanatuan City. Patient only finished high school and a retired government employee of DPWH. Three weeks PTA, patient noted a fluctuant mass along the umbilicus at left lower quadrant (LLQ) area while he was watching TV. Patient did not experience any pain, change in bowel movement, vomiting and has no fever. 1 week PTA, patient experienced crampy pain, with a pain score of 8/10, hence consulted a physician who gave him Buscopan, 10mg and Paracetamol. Patient was requested of abdominal ultrasound which revealed a cystic mass. 1 day PTA (August 4, 2013), there was persistence of pain and patient was given Buscopan 10mg/IV, but did not afforded relief. Patient was accompanied by his son to consult at UST Hospital where he was assessed and advised admission. August 5, 2013, patient was admitted in San Martin Ward of the University of Santo Tomas - Pay Hospital under the care of Dr. Johny Go with a chief complaint of abdominal pain and with no diagnosis yet. VS upon admission were: BP= 130/80, PR=79, RR=18 and Temperature=37.1. Complete Blood Count was done and with a result of low RBC (3.98) and Hematocrit (0.34). August 6, 2013, Colonoscopy was done with a diagnosis of colonic malignancy, distal transverse; internal hemorrhoid grade 1. Diagnosed to have stage IV colon cancer. Urinalysis was done. August 8, 2013, Chest X-ray was done with a result of apical pleural thickening, bilateral and a nodular density is seen over the right upper lobe. August 9, 2013, Complete Blood Count was ordered. Undergone segmental resectionof colon/anastomosis with a medical diagnosis of cystic mass p transverse colectomy. August 10, on his 1 day post-op. Remained on NPO. No flatus yet. VS, urine output and pain score were monitored every hour. VS at 12pm were: BP=120/70, PR=64, RR=18, Temperature=37.4 and pain score of 2/10. Urine Output was 40mL. JP drain was 10mL. Patient did not undergo any surgeries. Patient has no allergies on foods, medicines, latex and on any kinds of environment. He did not remember if he received vaccines. Patient has no

medicines taken at home. Patient has 7 to 8 hours and retires at 9 a.m. Patient does not have regular exercise. He is a smoker and alcohol drinker. He doesnt use any illicit drugs. H e is not sexually active. He has a diet low in fiber and high in fat and calories. Not fond of eating vegetables and cannot go without having meat every meal. Playing cards is his primary recreational activity. Patient lives in a concrete and well-ventilated house situated by the road together with his wife and son. Their relationship as a family was described by the patient as strong, very open and vocal about their feelings. Patient view his illness as a burden to his family because hospitalization is expensive. Coping mechanism includes always having a positive outlook in life.

REVIEW OF SYSTEMS

px: GP 67 years old male cc: abdominal pain dx: cystic mass transverse colectomy 8/9/13 admission 8/05/13 conscious, coherent, ambulatory initial VS as follows: BP 110/82 PR: 82 RR: 18 T: 37 pink parpebral conjunctiva anicteric sclarae pupil ertl 2-3 mm both eyes clear and equal breath sounds = crackles adynamic precardium

 apical pulse at 5th ics with murmurs abdomen= soft, flat, normal active bowel sounds, + palpable mass at left lower quadrant pulses full and equal + pain on the abdomen ROS 8/10/13 LOC: oriented to 3 spheres GCS: eyes-4, verbal-5, motor-5 on supine position cant move right arm due to frequent taking of blood pressure embolic stockings on both leg peripheral iv line on left dorsum D5NR1L @25gtts/min stomach pain on the left lower quadrant 2/10 (segmental resection of the colon/anastomosis) legs can slightly raised latest VS as follows 6pm PR=78 RR=19 T= 37.4 on IC urine dark yellow abdomen flat hypoactive no flatus with JP drain on left lower quadrant

COURSE IN THE WARD

August 5, 2013 Upon admission, the patient was kept on NPO to prepare the bowel for possible emergency surgery since he presented with abdominal pain localized to the left lower quadrant. He was given Buscopan 10 mg/IV for symptomatic relief of pain. Digital rectal exam was also done and revealed a tight sphincteric tone. Standard laboratory tests were done such as CBC, UA, serum tests, and 12 lead ECG. D5LRS to run at 35 gtts/min was started. The physician also requested for CT scan of the lower abdomen to provide a picture of the area, and to determine pathologic changes that might have caused the pain that was presented by the patient. Ciprofloxacin was also given. August 6, 2013 The abdominal pain persisted and was markedly increased upon deep palpation. The patient was given Buscopan 10 mg/tab. The CT scan of the lower abdomen was changed to CT scan of the whole abdomen with contrast for a more complete evaluation of the external structures of the abdominal organs. After CT scan, the patient was given cleansing enema to prepare the bowel for colonoscopy. After the diagnostic procedure, the patient was on soft diet and not allowed to eat foods high in fiber to decrease the amount of undigested material that passes through the intestine and decrease the formation of bulk. The patient had fever and was given TSB. Demerol was also ordered for abdominal pain. Lactulose was also given. Further laboratory diagnostics were also done such as: - CEA - TPAG - PT and APT

August 7, 2013 The patient started on bowel preparation. He was on general liquid diet and was given phosphosoda 45 cc. The patient was also given Abound sachet on 1 glass water q6h to provide for supplementary nutritional needs. The patient also received dulcolax and castor oil, and was encouraged to increase OFI. August 8, 2013 Today is the second day of the patients bowel preparation. He was on clear liquid diet and was again given another dose of phosphosoda 45 cc. PLRS at 20 gtts/min was started. Skin test for cefoxitin was also facilitated. Because the colonoscopy revealed that the patient already has colonic malignancy, Chest Xray was ordered to rule out metastasis before the doctors decide on what treatment would best suit the patient. Aside from this, the chest xray revealed apical pleural thickening and bilateral nodular infiltrates on the upper lobes. Peak Expiratory Flow Rate is a measure of a person's maximum speed of expiration, as measured with a peak flow meter, a small, hand-held device used to monitor a person's ability to breathe out air. It was ordered before and after the patients nebulization to monitor the patients breathing progress before and after the nebulization. Before the treatment, the patient had lower PEFR results compared to after the treatment. This reflects effectiveness of the treatment. 2 u of fresh whole blood was reserved for the patients surgery for possible bleeding risks. Due to the patients hypokalemia, 40 mEqs KCl was incorporated in the patients PNSS. However, because it was not tolerated by the patient, it was shifted to 40mcgs KCl + D5NM 1L and Kalium Durule August 9, 2013 After surgery, the patient was placed in high back rest in the PACU to promote optimum lung expansion. The patient also had Patient Controlled Epidural Anesthesia for his pain, so Demerol was discontinued.

Incentive Spirometry was done to aid in determining the patients lung status after surgery because undergoing surgery usually implies accompanying respiratory depression. Before the patient starts the incentive spirometry cycles, he was encouraged to push button of his Patient Controlled Analgesia because pain is known to decrease and interfere with his sustained maximal inspiration.

LABORATORY AND DIAGNOSTICS CBC NORMAL LEVEL August 5, 2013 120-170 4 6 x 1012 L 3.98 (low) 0.37- 0.54 0.34 (low) 11.6- 14.6 7.4-10.4 fL 6.70 fL (low) 0.50- 0.70 0.84 (high) 0.50- 0.70 0.84 (high) 0.20-0.40 0.15 (low) August 9, 2013 106 (low) 3.57 (low) 0.30 (low) 14.10 (high) 6.70 fL (low) 0.86 (high) 0.86 (high) 0.14 (low)

HGB RBC HCT RDW MPV Neutrophils Segmenters Lymphocytes

Hemoglobin is the known oxygen carrier in the blood. A decrease in its level may indicate anemias, severe hemorrhage, liver cirrhosis, leukemias, Hodgkins disease, excess IV fluids, cancer and kidney diseases. Hemoglobin in the body is dependent upon amounts of iron. A lack of available iron causes one type of anemia, due to the reduced production of hemoglobin. Remember that in the strictest sense, anemia is not in itself a diagnosis, but rather a symptom that there is something else wrong in the body. Hemoglobin usually mirrors RBC result. A low level of RBC suggests anemias and the similar diseases stated above. The hematocrit measures percentage by volume of packed red blood cells in a whole blood sample. Our patient has low levels of hematocrit for he is already experiencing anemia. RBC Distribution Width (RDW) is a parameter that measures variation in red blood cell size or red blood cell volume. High levels indicate mixed population of small and large RBCs. In anemia, there is high variation (anisocytosis) in RBC size (along with variation in shape poikilocytosis), causing an increase in the RDW. Mean platelet volume (MPV) is a measurement that describes the average size of platelets in the blood. Low level of MPV can indicate anemia in association with a low platelet value. Increases in neutrophils or segmenters mean that there is an acute bacterial infection, or an inflammatory disease such as pneumonia or tissue damage from surgery.

Low levels of lymphocytes can lead to conditions such as cancer or an infection in a person.

Potassium

BLOOD CHEMISTRY NORMAL LEVEL 3.8-5

August 8, 2013 3.28 (low)

The renal cortex contains over one million nephrons. Each nephron, as the basic functioning unit of the kidneys, mainly consists of three parts-renal glomerulus, renal tubule, and renal capsule. As a cortical cyst grows larger and larger, it can damage the functioning renal cells. This dysfunction in the kidneys may lead to hypokalemia. URINALYSIS Transparency Color pH Albumin Erythrocytes Urobilinogen RBC Pus cells Bacteria August 6, 2013 Turbid Dark Yellow 5.0 Positive Positive ++ 6-12/hpf 1-3/hpf ++

Urinalysis is best to diagnose UTIs and renal diseases, and for detecting metabolic diseases not related to the kidneys. Urine that is dark yellow in color is often a sign that one is dehydrated. This can also happen when an individual sweats a lot, and does not replenish the lost water. Other important factors that can lead to dehydration are excessive vomiting and diarrhea. Due to dehydration, the urine becomes concentrated with nitrogenous waste material, and transforms from a colorless liquid to a dark yellow colored one. A high concentration of nitrogenous waste can give urine a peculiar odor, along with changing its color.

The pH is lowered which means that the patient may be undergoing metabolic acidosis. The urine being turbid means that there is the presence of bacteria, pus, RBC, WBC and urates.

Proteinuria can be an early sign of kidney disease, because albumin is the very first protein found in urine when kidney dysfunction begins to develop. Urobilinogen is a colorless compound formed in the intestine after the breakdown of bilirubin by bacteria. Some of it is absorbed back into the bloodstream, while the remainder is excreted in urine (or bile or feces). Increased amounts of urobilinogen in the urine indicate an excessive amount of bilirubin in the blood. Elevated levels of urobilinogen may be due to liver diseases such as hepatitis and cirrhosis or liver metastases or liver infarction. Red blood cells in urine can be a sign of a number of issues involving the bladder and kidneys like blockages, stones or internal injuries. Malignancies can be associated with red blood cells in urine in some cases. In these instances, there may also be traces of cancerous cells sloughed off from the growth Bacteria or yeasts may indicate an infection. Pus cells are white blood cells that signify infection or inflammation in the kidneys and bladder. Since the urine has to pass through the kidneys and the bladder, it may pick up some pus cells from there before voiding. NORMAL LEVEL 4-5.5 August 8, 2013 3.08 (low)

Albumin

Hypoproteinemia may be due to decreased production or increased protein loss (eg, nephrotic syndrome, protein-losing enteropathy). A serum protein electrophoresis should be performed to evaluate the cause of the decreased serum total protein.

ECG August 5, 2013 Dx: 1. Sinus rhythm 2. Poor R wave progression V1-V3 Poor R wave progression on an ECG might indicate several problems. Possible cardiac issues include left ventricular hypertrophy, left bundle branch block, anterior or anteroseptal myocardial infarction, emphysema, chronic obstructive pulmonary disease (COPD) or pneumothorax.

CT SCAN- MRI August 6, 2013 The abdominal aorta is lined with calcific plaques Hypertrophic spurs are seen along the lumbosacral vertebrae

Impression:
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short segment of heteregenously enhancing concentric mass at the distal transverse colon with apparentncontiguous involvement of the posterior wall of the midtransverse colon suggestive of possible serosal infiltration which result to luminal obstruction with perilesional fat strandingsnand several lymph nodes. With these findings, a neoplastic process is primarily considered. Multiple hepatic metastases with necrotic change. Renal cortical cyst, left. Atheromatous abdominal aorta. Degenerative changes of lumbosacral spine.

Renal cortical cyst refers that a fluid-filled sac occurs on cortex of the kidneys. People are at increasing risk of developing kidney cyst as they are getting old. It is suggested about 50% people who are over 50 years old may develop one or several kidney cysts. The danger from a cortical cyst is that, as the cyst is enlarging over time, it can oppress renal tissues and impair kidney functions. *Evidence of renal metastasis of colorectal cancer in patient. Atheroma is an abnormal condition of the large arteries in which areas of the arterial walls become clogged with fatty tissue. It is part of the disease arteriosclerosis. Atherosclerosis describes the process by which damage to the artery wall leads to 'furring up' of the artery. This is the result of damage to the delicate inner lining (endothelium) of the artery by certain risk factors: *age - arterial disease increases with age. *smoking - especially cigarettes but also pipes and cigars if the smoke is inhaled. Smoking doubles the risk of a heart attack and of stroke (in patients with high blood pressure), and massively increases aggravates the progression of complications of peripheral arterial disease. The number of cigarettes smoked is less important than the mere fact of smoking. *high blood pressure - most vascular disease is associated with mild hypertension (high

pressure) because it is so common. The risks of disease are rapidly reversed by controlling the pressure. *diabetes *high cholesterol - the main culprit is low density lipoprotein (LDL) cholesterol. The overall cholesterol level is a good guide to LDL cholesterol levels. Ideally it should be around 5 mmol/l. *genetic factors - a family history indicates this. Men are more affected than women although the risks increase for women as they grow older. The renal cortex contains over one million nephrons. Each nephron, as the basic functioning unit of the kidneys, mainly consists of three parts-renal glomerulus, renal tubule, and renal capsule. As a cortical cyst grows larger and larger, it can damage the functioning renal cells. This dysfunction in the kidneys may lead to hypokalemia. Degenerative changes in the lumbosacral spine becomes common as people age. It can result to pain and neurological problems for patients. Liver metastases occur in the tissue of the liver, usually close to blood vessels. The liver has the second richest blood supply of the body, and therefore provides a very suitable environment for the growth of cancer cells. Liver metastases are foreign tissue growing within the liver. They either grow expansively (as a mass) or infiltratively (spreading through surrounding tissues). Physically, they grow and compress the surrounding liver tissue. A connective tissue rim is usually formed around the metastasis, and surrounding tissue is wasted away. Large metastases may even compress branches of the portal vein. Because they grow so quickly, liver metastases, like primary tumours, may outgrow their blood supply, resulting in death of the centre of the lesion.Some specific cancer metastases have unique effects. Metastases from pancreatic and breast cancers result in fibrous scar formation. Some metastases throw off blood clots that may occlude the portal or hepatic veins. Others may cause areas of calcification that are readily detectable using radiographic imaging.Metastases rarely cause death due to pure metastatic burden. Compression of the vena cava (hindering blood return to the heart), blockage of drainage outflows (resulting in lung infection, for example), and electrolyte imbalance caused by abnormal hormone secretion are some causes of death.

Concentric mass in the colon leads to narrowing of the lumen. The outline of the mass situated below and in the middle appears to be proximal to the posterior wall of the midtransverse colon. The midtransverse colon has an irregular and serrated appearance (or finely notched like the cutting edge of a saw). COLONOSCOPY August 6, 2013 Endoscopic description: There was a circumferential friable mass seen at the distal transverse colon approx. measuring 4 cm in length with 70% luminal narrowing. the hemorrhoidal vessels below the dentate line were engorged. Outcome dx: Colonic malignancy; distal transverse, internal hemorrhoids grade I Hemorrhoids are swollen blood vessels of the rectum. The hemorrhoidal veins are located in the lowest area of the rectum and the anus. Sometimes they swell so that the vein walls become stretched, thin, and irritated by passing bowel movements. Hemorrhoids are classified into two general categories: internal and external. Internal hemorrhoids lie far enough inside the rectum that you can't see or feel them. They don't usually hurt because there are few pain-sensing nerves in the rectum. Bleeding may be the only sign that they are there. Sometimes internal hemorrhoids prolapse, or enlarge and protrude outside the anal sphincter. When this happens, you may be able to see or feel them as moist, pink pads of skin that are pinker than the surrounding area. Prolapsed hemorrhoids may hurt because the anus is dense with pain-sensing nerves. They usually recede into the rectum on their own; if they don't, they can be gently pushed back into place. Those who prefer a diet high in processed foods are at higher risk. A low-fiber diet or inadequate fluid intake can cause constipation, which can contribute to hemorrhoids in two ways: It promotes straining during a bowel movement and it also aggravates the hemorrhoids by producing hard stools that further irritate the swollen veins. Grade 1 hemorrhoids are internal hemorrhoids which do not prolapse, or protrude out of the anus. For Grade 1 hemorrhoids doctors will most likely recommend a hemorrhoid treatment regimen of adding fiber to your diet and trying one of many new over-the-counter

hemorrhoid treatments.

PATHOLOGY REPORT August 7, 2013 Pathologic dx: Colonic mass; colonoscopy with biopsy: Adenocarcinoma Gross microscopic description: Microsection disclose fragments of a malignant neoplasm composed of cuboidal to columnar cells with round to ovoid, hyperchromatic to vesicular nuclei and scant cytoplasm. These are in glandular formations, some with cribriform formation and others infiltrating in cords into the muscularis mucosa.

CXR August 8, 2013

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Apical pleural thickening, bilateral. Nodular density is seen over the right upper lobe

Apical pleural thickening refers to pleural thickening of the apical portion of the lungs. The apical portion, or apices, of the lung is the rounded top portion of the lung. The lungs are covered by two thin layers of tissue. These layers are known as the pleura. The pleura may become hardened and lose it elasticity due to infection or by some other disease process such as mesothelioma or asbestosis. When the pleural layers become hardened it becomes increasingly difficult to breathe due to restricting the lungs ability to expand during inhalation. Symptoms of apical pleural thickening are similar to other respiratory disease processes. They include shortness of breath, chest pain and difficulty breathing during exercise. There are many causes for apical pleural thickening as it is a result of any inflammation in the lungs. Some causes included; bacterial pneumonia, chemotherapy, infection and lupus.

Lupus is a key factor as it causes inflammation to so many body tissues. Treatment for apical pleural thickening can only be treated surgically as the hardened areas of the lungs are scar tissue and will need to be removed. Thus relieving the pressure off the lungs allowing them to expand freely. Asbestos Exposure Chronic exposure to asbestos is one of the most common causes of pleural thickening. The tiny asbestos particles can bypass the lung filtration system and enter the lungs, where they imbed within the tissue, resulting in inflammation and scarring. Asbestos-related thickening normally occurs in conjunction with other medical conditions, including fibrosis and pleural effusion. Although asbestos disease is a serious condition, it is very treatable with medication that allows improved breathing by reducing inflammation. However, asbestos-related thickening has been linked to formation of a serious form of cancer called mesothelioma. *Patient was an employee in the Department of Public Works and Highways. What are pulmonary nodules? A pulmonary nodule is a small round or oval-shaped growth in the lung. It is sometimes also called a spot on the lung or a coin lesion. Pulmonary nodules are generally smaller than 3 centimeters in diameter. If the growth is larger than that, it is known as a pulmonary mass. A mass is more likely to represent a cancer than is a nodule.

Metastatic tumors (tumors that have spread to the lungs from cancer in another part of the body). *Patient is diagnosed with Stage IV colon cancer that has metastasized to the lungs .