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Case II : ICM 2

A 19 years old man, Mr Yunus comes to Emergency Department at 11PM complaining about
whole abdominal pain. It started from pain at right lower quadrant since 10 days ago, and radiating to
whole abdomen since 4 days ago. It is constant in feature, and increasing from time to time. At first the
quality of pain is 4/10, and now the quality of pain is increasing since 4 days ago, about 8/10. The pain is
also increasing when he coughs or moving his body. Nothing he can do that could reduce his pain.

The patient is also complaining of fever since 10 days ago, at first it was intermittent fever, with
the highest temperature reached at night, and it was progressing day by day. Last 2 days, the fever
became constant.

The abdominal pain and fever is accompanied with vomiting and also diarrhea. The patient was
vomiting 3-4 times a day, the content of the vomit is indigested food, no blood is in it. The frequency of
diarrhea is 5-6 times a day, the content of the defecation is liquid stool, no blood in it.

The amount of urine is decreased since 2 days ago, it becomes dark, but no pain in micturition.

His appetite is decreasing since 10 days ago, and he lost weight about 3 kg within 10 days.

No history of previous abdominal pain. The patient is a labour in a factory, no history of similar
disease in his neighbourhood or his workplace.

He was brought to general practitioner this evening and was given advice to go to hospital. He
never seek medical attention before.

On physical examination: The patient is alert, lethargic, BP 110/70 mm Hg, HR 112x/m, RR


32x/m, Temp 39.0 C. The patient is slightly malnourished, his weight is 54 kg, his height is 168cm. The
patient is not anemic and not icteric.There is decreased turgor of the skin. There is coated tongue. At
thoracal region : symmetrical chest shape and expansion, equal breath sound, no ronchi nor wheezing.

At abdominal region :distended, no bowel sound. Negative liver dullness. There is tenderness,
rebound tenderness, and muscle rigidity at all of abdominal areas. Punctum maximum of tenderness is
at right lower quadrant of abdomen. At digital rectal examination : normal sphincter tone, the rectal
mucosa is smooth, tenderness at all direction, normal rectal vault, normal prostate. At gloves : there is
stool but no blood is found.

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Questions to be answered :

1. What has happened to Mr Yunus?

2. What are the possible causes for his condition?

3. What other examinations ( laboratory and radiology) do you need to make a


diagnosis and to seek for complication of the disease?

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Laboratory findings

Hb 11.2 gr/dL.Ht 40 WBC 3.500/mm3 Platelet : 160.000/mm3.

Ur 88 creatinine 0.8.Sodium : 135 Potassium 3.7 Random blood glucose : 95

BGA : pH 7.360 pCO2 28 HCO3 18 TCO2 17 BE -6.6 saturation 97.0 C

PT/aPTT : normal

Widal test :

Titer of Salmonella typhi-O : 1/320

Titer Salmonella typhi-H : 1/320

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Radiology findings

At Antero-posterior thoracal x-ray

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At erect abdominal x-ray

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5. What is the working diagnosis?

5. What will you do to provide initial management? What are your reasons?