Post on 17-Jan-2018
description
GASTROINTESTINAL
CASE STUDY
• Symptom free during the intervening period until 8 months prior to current admission
• February 2010– Colicky but tolerable abdominal pain • Refers to hollow organs
– Bloatedness– Abdominal distention which subsides upon
passage of flatus or stool• Intermittent abdominal distention is the hallmark of all
forms of intestinal obstruction
• 4 Weeks Prior to Consult – Vomiting of previously ingested food occurring 1-2
times/week• Possible upper bowel obstruction
– Progressed to daily intolerance of both solid and soft diet (daily)
– Abdominal distention becomes more frequent and severe
– Colicky pain localized in RLQ– Anorexic• Lost 20-30% of her weight during the last month• Weight loss may be due to her TB since she denies a
history of cancer in the family – LMP is 18 days ago
• On admission– Stable vital signs– Hyposthenic• Lack of strength or weakness
– Ambulates freely but with evidence of muscle wasting
– Minimally worked up and diagnosed but she cannot be cleared for definitive intervention due to high risk for pulmonary circulations
– Wasting fast, nutrition is a compounding problem
Additional Questions Needed• Other symptoms felt before? – Fever, constipation, diarrhea?
• TB related symptoms?– Cough, night sweats?
• Abdominal pain– Duration? Hours? Days? – Pain scale? 1-10?
• Patient was minimally worked up upon admission– What tests were done?– How did they treat her?
• Dehydrated?– Sunken eyeballs, dry oral mucosa, poor skin
turgidity• Anemic?– Pale conjunctivae, pallor
Is there a history of previous abdominal surgery?
NONE
What are the pertinent abdominal and rectal exam PE findings?
• Inspection– Contour = protruberant
• Due to accumulation of gas and fluid proximal to and within the obstructed segment
– Tense and shiny– Visible peristalsis = increased abdominal activity
• Abdominal girth should be measured!• Auscultation– Hyperactive
• Bowel is trying to overcome the obstruction– Hypoactive
• Already a late sign indicating peristalsis
• Palpation– Are there any palpable masses?• A palpable mass in the right iliac fossa implies colonic TB
• Percussion– Tympanitic• Presence of excessive gas within the bowels
• Rectal Exam– Patency of anal sphincter– Any discomfort – Gross or occult blood• Suggests a late strangulation or malignancy
Chest X-ray
Check- Opacifications- Cavity-High diaphragm
Overall- TB[?]
Abdominal X-ray
Check- Bone in legs[?]
Check- Narrowing on the lower right side
Check- Ascending, descending or transverse
Primary Clinical Impression
Gastrointestinal Tuberculosis
Intestinal TuberculosisColonic Tuberculosis