Identification:

This is Getachew Assefa, a 63 year-old male patient whose permanent residence is in Hayat, Bole Kifle
Ketema, Addis Ababa. He is 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 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 lcoated 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 kg 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 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:

He is married and has 3 sons and 1 daughter. All of his children are alive and in good
health, with no known illnesses or medical conditions. He is socially active and participates in edir and
equb. He regularly prays, together with his family.

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 arm pit 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 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
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Physical Examination:
General Appearance: He is awake and conscious. He appears chronically sick-looking and he is not in
cardiorespiratory distress.
Vital Signs:BP:140/80, PR:78, RR:21, Temperature:36.5Skin: 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: PR examination was not performed
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.