Identification:

This is Getachew Assefa Kebede, a 63 year-old male patient whose permanent

residence is in Hayat, Bole Kifle Ketema, Addis Ababa. He is Orthodox Christian in
his religion and is married. He works as a tyre-man. He was referred from
Teklehaimanot General Hospital, and arrived at Saint Paul’s Hospital on Miyaziya 1,
2016 in a relative’s car and walked by himself. He was admitted to the Department of
Surgery 3rd floor East Ward, Bed Number 23. The patient was clerked on Miyaziya 2,
2016 at 01:50 LT at night. The historian was the patient himself with no language
barrier. He was aided by his daughter. The historian seems reliable.

Previous Admission:
He was admitted to TekleHaimanot General Hospital on Megabit 27, 2016. He then
was referred to St. Paul’s for better management and surgery.

Chief Complaint:
Worsening of abdominal pain of 1-month duration

History of Present Illness:

This is the second admission for this 60-year-old male who states having a worsening
of abdominal pain of 1-month duration. The pain is located in the left lower quadrant
area and does not radiate to any other site. It is cramping in quality and gets worse
when the patient is standing, for instance while he is praying, and also whenever he
lies on his sides. It has no known relieving factors.

The first episode of pain occurred around a year ago. It was of an intermittent nature,
but has markedly increased in severity during the past month, rendering the patient
unable to work and confining him to bed.

The pain was accompanied by abdominal distention, passage of blood-stained stool,

vomiting, intermittent constipation, weight loss of 12 kgs and loss of appetite of
similar duration.

Otherwise
No history of smoking
No history of alcohol
No personal or family history of colorectal cancer
No previous diagnosis of IBD
No family history of IBD
No history of previous colonoscopy showing significant polyps or suspicious lesions
No history of radiation therapy to the abdomen or pelvis
No history of chronic NSAID use
No history of previous colorectal surgery
No history of chronic diarrhea
No history of flatus
No history of fever and chills
No history chronic cough, contact with a chronic cougher or previous TB treatment

The patient has undergone colostomy on Miyaziya 1, 2016 and reports a marked
improvement in his condition.
Past medical and surgical history:
The patient doesn’t remember having a major childhood illness. • No history of
surgery. • No history of trauma, serious injuries or fractures. • No history of
hypertension. • No history of DM.

Personal, Family and Social History:

The patient is a native of Addis Ababa, where he has spent his entire life. From a
young age, the patient has led an active lifestyle, indicative of a healthy childhood. He
has attended secondary school up to 12th grade. He then got married to when he turned
28. His wife is alive and well. His parents have passed away of old age. He has 3
siblings: one brother and 2 sisters. They are alive and well as well and have no known
illnesses. He enjoys a supportive family environment, with three sons and one
daughter, all of whom are in good health and without any significant medical issues.
He lives in a three-room house with 4 functional windows and 3 doors, separate
kitchen and toilet. He lives there with his wife and his daughter. He uses tap water for
drinking and cleaning. His social engagements are robust, as he actively participates
in community activities such as ‘edir’ and ‘equb’. Additionally, he maintains a
spiritual routine, praying regularly with his family, which reflects a strong family
bond and a sense of community belonging.

Functional Inquiry(Review of Systems):

General: mentioned in the HPI

HEENT:
• Head – no history of injury or headache
• Ears – no history of pain, hearing loss, vertigo, or discharge
• Eyes – no history of vision disturbance, or eye strain, lacrimation, itching, or
redness.
• Nose – no history of epistaxis, discharge, sinusitis or difficulty with smelling
• Mouth and Throat – no history bleeding gums, sore throat

LGS: no history of swelling in the armpit or in the inguinal area, no history of breast
lumps or discharge from the nipples

Respiratory System: no history of cyanosis, dyspnea, orthopnea or PND, no history of

cough, sputum, dyspnea or wheezing

Cardiovascular System: no history of chest pain or palpitations, dyspnea, orthopnea,

paroxysmal nocturnal dyspnea, edema

Gastrointestinal System: Abdominal pain of 1-month duration, cramping in quality,

confined to the LLQ area. Vomiting of similar duration. The vomitus was reddish-
black in color and amounted to 2 coffee cups. Loss of appetite of similar duration.
Abdominal distention of similar duration. Weight loss of 12 Kgs of similar duration.
Intermittent constipation and failure to pass feces of similar duration. No history of
flatulence, no yellowish discoloration of sclera or hemorrhoids.

Genitourinary System: The patient reports occasiional complaints of dysuria, even

before his main complaint of abdominal pain started, but there is no nocturia,
polyuria, hematuria or incontinence.
Metabolic: No history of polydipsia, polyphagia.

Neurological System: No history of dizziness, extremity numbness, abnormal

sensation

Psychology: No history of anxiety or depression

Integumentary System: No history of ulceration, color change, hair loss, or any

changes in fingernails

Musculoskeletal System: No history of deformities, or gait changes

Hematologic: No history of easy bleeding or bruising

Immunologic: No history of seasonal allergies

Physical Examination:
General Appearance: The patient is awake and conscious. He appears chronically
sick-looking and he is not in cardiorespiratory distress.

Vital Signs:
BP:140/80 from the right brachial artery in sitting position
PR:78 from the right radial artery, regular in rhythm, and full in volume
RR:21 breath per minute, quiet and regular
Temperature:36.5 taken from the right axilla on the evening at 02:27 LT

Skin: Normal in appearance, texture, and temperature

Scalp: Normal
Pupils: Equally round, reactive to light and accommodation, sclera and conjunctiva
normal.
Tympanic membranes and external auditory canals: normal.
Nasal mucosa: normal.
Oral pharynx: normal without erythema or exudate. Tongue and gums are also
normal.

Neck: Easily moveable without resistance, no abnormal adenopathy in the cervical or

supraclavicular areas. Trachea is midline and thyroid gland is normal without masses.
Carotid artery upstroke is normal bilaterally without bruits. Jugular venous pressure is
measured as 8 cm with patient at 45 degrees.

Chest: Lungs are clear to auscltation, no use of acessory muscles, no crackles or

wheezes

Abdomen: There is a clean surgical dressing over the lower abdomen. There is also a
pink fleshy mass over the LLQ area of the abdomen with no output, indicating the
patient had undergone colostomy.
Extremities: No cyanosis, clubbing, or edema are noted. Peripheral pulses in the
femoral, popliteal, anterior tibial, dorsalis pedis, brachial, and radial areas are normal.

Nodes: No palpable nodes in the cervical, supraclavicular, axillary or inguinal areas.

Genital/Rectal:

Neurological: Cranial nerves II-XII are normal. Motor and sensory examination of the
upper and lower extremitiesis normal. Gait and cerebellar function are also normal.
Reflexes are normal and symmetrical bilaterally in both extremities.