1. GASTROINTESTINAL

2. 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

3. 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

4. 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

5. 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?

6. Dehydrated? – Sunken eyeballs, dry oral mucosa, poor skin turgidity Anemic? – Pale conjunctivae, pallor

7. Is there a history of previous abdominal surgery? NONE

8. 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

9. 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

10. Chest X-ray Check - Opacifications - Cavity -High diaphragm Overall - TB[?]

11. Check

12. Abdominal X-ray Check - Bone in legs[?]

14. Check - Narrowing on the lower right side

17. Check - Ascending, descending or transverse

19. Primary Clinical Impression Gastrointestinal Tuberculosis Intestinal Tuberculosis Colonic Tuberculosis