DUMAG, ARIANNE CAMILLE T.

SEC B - GROUP 8
PM WARD (DR. Deduyo)

Date of Interview: April 13, 2023

Informant: patient
9 days confinement

I. GENERAL DATA
R.D, 57 years old, male, married, construction worker, Filipino, Roman Catholic,
born on November 15, 1965 at Leyte, currently residing at Taguig City, admitted for the
1st time last April 4, 2023 in Pasay City General Hospital.

II. CHIEF COMPLAINT

Abdominal pain

III. HISTORY OF PRESENT ILLNESS

6 mos PTA, patient went to PGH due to sudden generalized abdominal pain
described as burning with a pain scale of 8/10, radiating to the lower back,
aggravated by hunger and eating sour foods which is alleviated by food intake.
Associated with loss of appetite, dysphagia, vomiting and increase in abdominal
area. No other associated symptoms such as fever, headache, difficulty in breathing and
no change in stool. Tests done were CT scan, ECG, UTZ, X-ray, CBC, U/A, and F/A.
Results showed ascites, stomach ulcer and an abdominal mass. He was given
medications which are unrecalled, which gave relief to the patient. He was also told that
he has possible prostate cancer.
1 month PTA, along with abdominal pain, the patient's associated symptoms
were vomiting which led him to have a soft diet, irregular bowel movement with 1 week
interval, also change in stool caliber, stool was hard, black that occured about 3x. No
medications taken and no consultation done.
3 weeks PTA, he consulted at lung center due to abdominal pain, CT Scan was
done where it showed an intra abdominal mass. A thoracentesis was also done on his
left lung.
Few hours PTA, still with the persistence of abdominal pain, vomiting, irregular
bowel movements, passage of hard stool he went to PCGH with subsequent admission.

IV. PAST MEDICAL HISTORY

Patient's claims to have complete childhood immunizations. COVID 19
vaccination was not confirmed. He had no other childhood illnesses apart from chicken
pox, mumps and measles.
 He has no maintenance medications but is taking multivitamins (Centrum) once
a day and Alaxan every time his body is sore after work for 10 years now. . No food
or medication allergies. No previous surgery, accidents and trauma. No history of
hypertension, diabetes, stroke, renal disease, and TB.

V. FAMILY HISTORY
Patient’s father died at 40 y/o due to an accident. Patient’s mother died at 96 y/o
due to old age. He is 7th born among 12 siblings, eldest brother died due to snake bite,
3rd brother was diagnosed with arthritis and asthma at 40 y/o, other siblings are
apparently healthy. He has 5 children all are apparently healthy. No known
heredofamilial diseases such as, arthritis, gout, psychiatric problem, seizures disorder,
thyroid disease and pulmonary tuberculosis.

VI. PERSONAL & SOCIAL HISTORY

The patient is married for 25 years, wife is apparently healthy. The patient
currently works as a constructor. He currently lives in a boarding house at Taguig with
her son and nephew, toilet is de buhos, and room is well ventilated. No pets.
Patient is a non-alcoholic drinker non-smoker, No history of drug use. Drinking is
from a refilling station. Garbage is everyday. He eats 3x a day of food from carinderia
and prefers pork adobo, fried foods, seldom vegetables. But most of the time when he is
at work, he skips meals. He drinks a glass of milk every morning, has weekly exercises.
He usually has 3hrs of interrupted sleep.

VII. REVIEW OF SYSTEMS

Constitutional: (-) Fatigue, (+) Chills, (+) Fever, (+) Weight Loss (4kg Loss; From
53kg To 49 Kg), (-) Weight Gain

Integumentary: (-) Dryness, (-) Rashes, (-) Itchiness, (-) Lumps, (-) Changes In Color

Hair: (-) Increase Hair Fall, (-) Baldness, (-) Excess Hair

Head: (-) Headache, (-) Dizziness, (-) Tenderness, (-) Trauma

Eyes: (+) Blurred Vision, (+) Use Of Glasses/Lenses, (-) Eye Pain, (-) Redness, (-)
Double Vision, (-) Photalgia, (+) Lacrimation

Ears: (+) Hearing Problem (L Ear), (-) Ear Pain, (-) Itching, (-) Discharge

Mouth And Throat: (-) Dysphagia, (-) Hoarseness, (-) Sore Throat, (-) Odynophagia,
(-) Use Of Dentures, (-) Bleeding Gums, (-) Toothache, (-) Mouth Sores

Neck: (-) Pain, (-) Lump, (+) Stiffness

 Breast: (-) Pain, (-) Lump, (-) Discharge

Respiratory: (-) Cough, (-) Sputum, (-) Hemoptysis, (-) Dyspnea, (-) Wheezing, (-) Rales

Cardiovascular: (-) Chest Pain, (-) Edema, (-) Orthopnea, (-) Paroxysmal Nocturnal
Dyspnea, (-) Palpitations, (-) Cyanosis, Easy Fatigability (-)

Renal: (-) Polyuria, (-) Dysuria, (+) Nocturia, (+) Urgency, (-) Gross Hematuria, (-)
Retention, (-) Flank Pain, (-) Reduced Caliber Or Force Of Urinary Stream, (-) Dribbling, (-)
Straining, (-) Hesitancy

Genitalia: (-) Pain, (-) Swelling, (-) Ulcers, (-) Itching, (-) Discharged

Peripheral Vascular: (+) Leg Cramps, (+) Varicose Veins

Musculoskeletal: (-) Back Pain, (-) Muscle Weakness, (-) Muscle Pain, (-) Joint Pain, (-)
Joint Stiffness, (-) Joint Swelling,

Neurologic: (-) Paralysis, (-) Numbness, (-) Tremors, (-) Memory Loss, (-) Seizures, (-)
Changes In Mood

Hematologic: (-) Pallor, (+) Easy Bruising, (-) Bleeding

Endocrine: (-) Heat/Cold Intolerance, (+) Excessive Sweating, (+) Polydipsia, (-)
Polyphagia

Psychiatric: (-) Nervousness, (-) Hallucinations, (-) Depression, (-) Anxiety

VIII. COMPLETE PHYSICAL EXAMINATION

General Survey
Patient is medium built, well nourished, well developed, conscious, coherent,
cooperative, ambulatory, and not in cardiorespiratory distress.

Vital Signs Anthropometrics

BP HR HT 5’2
120/80 mmHg 77/min

RR 22/min T 36.9℃ WT 49 kgs

Integument
The skin is brown in color, warm, dry to touch, has good skin turgor, no superficial
blood vessels, with some hyperpigmentation. Hair is thin, soft, and sparse. CRT is less
than 2 seconds.

HEENT
Cranium The head is midline in position with no abnormal head
movement. The skull is normocephalic, oval in shape and
symmetrical. There are no visible lesions, scales, and
deformities.The hair is slightly gray in color. The cranium is
normocephalic and symmetrical. There is no tenderness,
swelling, abnormal prominence, and depression. The hair is
smooth and dry.

Face The face is symmetrical, skin is brown in color, soft and

smooth with no lesions, and with some hyperpigmentation.

Eyes Eyebrows and eyelashes are black in color. Eyelashes are

short and present in both upper and lower eyelids.
Conjunctiva is pink in color. Sclera is anicteric. Iris is round
and brown in color. Pupils are round and symmetrical, can
accommodate, reactive to both direct and indirect light
reflex.

Ears Symmetrical, auricle normal size, patent ear canal.

Nose Nose is symmetrical and pointed. No alar flaring. Turbinates

are pinkish, no edema, no swelling, and no secretions.

Mouth Lips are pink and symmetrical. Buccal mucosa and gums
are pinkish, moist, with no lesions. Teeth are yellowish with
complete set of teeth. Tongue is pinkish in color, in midline
position upon protrusion and retraction, and can move
without difficulty. No tremors, no coating, no lesions noted.
The hard and soft palate is pinkish, no masses, lesions and
bony protuberance.

Neck Skin is fair in color. Normal in size, symmetrical with full

range of motion . Trachea is in the midline. Thyroid is not
visible but palpable with no tenderness, moves with
deglutition.
Chest & Lungs
​Skin is fair, no subcutaneous blood vessels seen, no lesions, with good muscle
development. No narrowing or widening of intercostal spaces Equal chest expansion. No
tenderness, no masses, no crepitations. No wheezes, crackles, and rhonchi. Resonant
all over. Normal breath sounds.

Cardiovascular
​Upon inspection, there is no bulging nor depression of the pericardium. Carotid
artery pulses are palpable, strong and bounding. Radial artery pulses palpable, strong
and bounding. Right & Left brachial artery pulse are palpable, strong, and bounding.
Femoral artery not palpated. Popliteal artery pulses palpable, strong and bounding.
Posterior tibial artery pulses palpable, strong and bounding. Dorsalis pedis artery pulses
palpable, strong and bounding. Adynamic precordium, apex beat at 5th LICS MCL. No
heaves, thrills and lifts. Apex beat is at the 5th intercostal space left midclavicular line.
S1 is loudest at the apex and S2 is loudest at the base. No S3, S4, and extra heart
sounds.

Abdomen
Upon inspection, the abdomen is slightly globular, symmetrical, no skin lesions,
no superficial veins, no scars, no striae, the umbilicus is inverted, and no visible
peristalsis. On auscultation, normal bowel sounds, no bruits and no friction rub. On light
palpation, with tenderness. On deep palpation, with tenderness and pain on the
lower left and lower right. The liver, spleen, and kidneys are not palpable. On
percussion, it was dull for the whole abdomen. Traube’s space is intact, no obliteration,
no splenomegaly. (+) Costovertebral angle tenderness for both right and left
kidneys. Negative for fluid wave test and shifting dullness.

Extremities
Upper Extremities
Patient’s skin is brown in color, nail beds are pinkish, there is no swelling of nail
folds, no lesions, no edema, no tenderness, and no bone deformities seen. Intact range
of motion. There are no noted lesions on both lateral upper arms, no gross deformities.
There is no pain felt upon palpation on the sternoclavicular joint, acromion, coracoid
process, and greater tuberosity.
Lower Extremities
The skin is brown in color, no gross deformities, lesions, and nodules. Posteriorly,
cervical spine is concave, no joint tenderness, no stiffness, no crepitations. There are no
noted discoloration of the knee, no nodules, no tenderness, no crepitations. Flexion and
extension of the knee are normal and without pain.

Neuro Exam
Cerebrum: The patient was conscious, coherent, and cooperative. He was oriented as
to person, time and place. He was able to demonstrate object recall, had no difficulty to
follow simple and complex commands, and able to do calculation, intact immediate,
recent and remote memory.
Cerebellum: Patient was able to execute a finger-nose test.

Cranial Nerves:
CN I Intact

CN II Both pupils are equally reactive to light and

accommodation.

CN II / III Pupils are equally round and respond to direct light and
consensual stimuli

CN III / IV / VI Patient has full extraocular muscle movements

CN V Able recognize sensations of pain and light touch

bilaterally on the face, able to demonstrate normal and
force in the muscle of mastication

CN VII Able to demonstrate different facial expression

CN VIII Patient was able to repeat words whispered to her and

able to localized the sound.

CN IX / X Uvula is at the midline. Gag reflex was not assessed,

Both sides of pharyngeal wall are symmetrical, no
hoarseness of voice noted.

CN XI No fasciculation, tremors or atrophy noted. Patient was

not able to shrug her shoulders symmetrically.

CN XII Tongue is at the midline and symmetrical when

protruded, no atrophy nor involuntary movement
observed.

Motor Function: No muscle atrophy/hypertrophy, no fasciculation noted. There is no

rigidity and involuntary muscle movement noted. Patient has good muscle tone.
Reflexes: DTR are normal. Biceps, triceps, knee and ankle are 2+. Patient is negative
for Babinski.
Sensory: Intact sensation for pain, crude touch and position sensation for both upper
and lower extremities.
Meningeal: Brudzinski, Kernig’s sign, and nuchal rigidity are all negative.
IX. SALIENT FEATURES
● Abdominal pain
○ Burning quality, radiating to the back , 8/10
○ Aggravated by hunger & eating sour foods
○ Alleviated by food intake
● Loss of appetite
● Dysphagia
● Vomiting
● Ascites
● Stomach ulcer
● Abdominal mass
● Weight loss
● Irregular BM, change in stool, Black stool
● Intake of Alaxan (10 yrs)
● Diet (mostly meat & fried foods)
● Abdomen - globular, tender, pain upon palpation

X. PRIMARY DIAGNOSIS & DIFFERENTIAL DIAGNOSIS

PRIMARY IMPRESSION: ABDOMINAL MASS T/C MALIGNANCY
Basis:
● Abdominal pain
○ Burning quality, radiating to the back , 8/10
○ Aggravated by hunger & eating sour foods
○ Alleviated by food intake
● Loss of appetite
● Dysphagia
● Weakness, Vomiting
● Ascites
● Stomach ulcer
● Abdominal mass
● Irregular BM, change in stool, Black stool
● Intake of Alaxan (10 yrs)
● Abdomen - globular, tender, pain upon palpation

Differential DIagnosis
RULE IN RULE OUT

Esophageal cancer (+) abdominal pain (-) chest pain

(+) dysphagia (-) hoarseness
(+) weight loss (-) odynophagia
(+) back pain (-) supraclavicular
lymphadenopathy
(-) dyspnea
 Gastric cancer (+) abdominal pain *cannot totally rule out
(+) abdominal mass without endoscopy
(+) weight loss
(+) loss of appetite
(+) vomiting
(+) dysphagia

Gastric lymphoma (+) abdominal pain (-) nausea

(+) weight loss
(+) loss of appetite *cannot totally rule out
(+) vomiting without endoscopy
(+) bleeding

XI. PATHOPHYSIOLOGY & EPIDEMIOLOGY

Pathophysiology
● Abdominal, or stomach, cancer is when abnormal cells grow uncontrollably
anywhere between the groin and the chest. The organs that cancer may affect
include: intestines, liver, colon, gallbladder, stomach, pancreas, esophagus and
many blood vessels
● Abdominal cancer often spreads to the lymphatic system and lungs. When old or
damaged cells in the abdomen divide and multiply uncontrollably, a malignant
mass or tumor is formed inside an organ in the abdomen. If not treated, this
cancer can interfere with vital processes of these organs as well as spread to
other parts of the body such as the lymphatic system and lungs.

Epidemiology
● WORLDWIDE
○ Esophageal, gastroesophageal junction, and gastric cancers are among
the most common of human malignancies, with 1.5 million global new
cases diagnosed in 2018.
○ In the United States, a lower risk area, it is estimated that in 2020,
■ esophageal cancer will be diagnosed in 18,440 people and cause
16,170 deaths;
■ for gastric cancer, 27,600 new cases will be diagnosed and 11,010
deaths will occur.
■ Small intestine cancers are rare.

● PHILIPPINES
○ Majority (95%) of cancer in the stomach are adenocarcinoma
○ 3,129 new cases and 2,609 new deaths attributed to stomach cancer in
both sexes (PH Cancer Facts & Estimates 2010)
○ Rarely occurs before the 4th decade, incidence rises thereafter, peaking
at 60-70 years
○ 2x as common among men as women
 ○ More common in lower socioeconomic status (reflecting dietary habits &
environment exposures)

XII. DIAGNOSTICS
● Endoscopy with biopsy
○ Gold standard, most sensitive and specific diagnostic method
○ Determines histology, location, degree of obstruction, and extent of lesion
● CT scan of chest & abdomen
○ Determines the local extent and relationship to adjacent structures and
distant metastasis
● Endoscopic ultrasound
○ Able to identify distinct layers of the esophageal wall, thus providing an
assessment of the depth of tumor invasion
○ Maybe useful for characterizing and providing tissue diagnosis of
abnormal lymph nodes
● Thoracoscopy & Laparoscopy
○ Offers direct visualization and histopathologic diagnosis for nodal status &
extent of local invasion and metastatic disease
○ Laparoscopy reserved for medically fit patients with potentially resectable
disease
○ Role of laparoscopy: to rule out peritoneal implants and to evaluate for
liver metastasis

XIII. MANAGEMENT

Depending on the cause of the mass, tx may range from conservative to radical surgery.

1. MEDICAL - analgesic, anti-inflammatory, antimicrobial, hormonal therapy

2. SURGERY
a. Aspiration and/or drainage (cystic mass)
b. Removal of the mass and part of affected organ or
c. Removal of entire organ & associated with removal of the draining lymph node if
malignant tumor
3. CHEMOTHERAPY and/or RADIOTHERAPY - used to shrink the tumor before surgery
a. ADJUVANT THERAPY - when there is risk of recurrence or when there is
micrometastases

Localized Cancer Treatments

● Surgery
○ Can cure at least 40% of cancer patients (early stage); but unfortunately,
60% of patients present with metastatic disease
 ○ Curative intent surgery: complete excision of tumor with adequate margin
of normal tissue
● Radiotherapy
○ Use of ionizing radiation that causes breaks in DNA of cancer cells
● Others
○ Stent placements using endoscopic techniques - for GI or biliary
obstructions

Systemic Cancer Treatments

● Chemotherapy
○ Agents that target the DNA structure or the segregation of cancer DNA as
chromosomes in mitosis
● Targeted treatment
○ Molecules that interact with a distinct target that is significant in
maintaining the malignant state of tumor cells or cells that they express
● Cancer biologic therapy
○ Agents that manipulate the host-tumor interaction in favor of the host
○ Distinguished from targeted treatment since it requires an active response
on the part of the tumor to achieve a therapeutic effect
● Immunotherapy
○ Agents that leverage on the host’s own specific & potent immune system
against cancer leading to durable clinical tumor regression

XIV. COMPLICATION & PROGNOSIS

Complications
● Ascites
● GI perforation & sepsis
● Permanent damage to kidneys, liver, or pancreas
● Metastasis
● Secondary obstruction of the small & large intestine

Prognosis - Survival in patients depends on the stage of the disease

● Esophageal cancer
○ Squamous cell carcinoma & adenocarcinoma, stage-by-stage,
appear to have equivalent survival rates
○ Lymph node metastases are associated with low survival rates
○ In 2012-2018 - overall survival rate for esophageal cancer was
20.6%

● Gastric cancer
○ 2010-1026, overall 5-year survival rate was 32%
○ Worldwide - Gastric CA is the 3rd leading cause of death
XV. CONCEPT MAP

REFERENCES:

Jameson, J. L., Fauci, A. S., Kasper, D. L., Hauser, S. L., Longo, D. L., & Loscalzo, J. (2022). In
Harrison's Principles of Internal Medicine (21st ed.,). essay, McGraw-Hill Education.

De Vita, et al. Principles and Practice of Oncology, 11th ed, 2018