IM Gastroenterology Rotation

Health History
8/27/2018 10:30 AM

General Data:
Patient E.R, a 74 year old male, senior citizen, Roman Catholic, born on
March 15, 1944, currently residing in San Remigio, Cebu. Patient is admitted for the first time
at VSMMC on August 24, 2018 at 2:00 AM.

Chief Complaint: severe abdominal pain

Informant: Patient, 70% reliability

Son, 50% reliability

History of Present Illness

2 weeks PTA, px presented with a sudden onset of a burning abdominal
pain (epigastric region) 5/10, radiating to the back; pain is aggravated upon eating. No
dyspnea, no fever, no urinary frequency, no urinary hesitancy and incontinence noted. No
palliative measures recognized by the px. Patient sought consult at a local health center and
was prescribed with Kremil-S (178 mg/ 230 mg/ 30 mg) for relief and another medication for
which px cannot recall.

1 week PTA, patient’s condition persisted, presented with occasional

diarrhea now associated with melena and dizziness. No hematemesis, no dyspnea, no
syncope, no nausea, no vomiting.

10 hours PTA, while px was cutting woods, px experienced severe

generalized pain 8/10, accompanied by pallor and dizziness. No syncope, no nausea, no
vomiting. This prompted the px to seek consultation at Bogo Hospital but was referred to
VSMMC for further management.

Past Medical History

No hypertension, no diabetes, no history of cardiac disease, no history of
exposure to TB. No previous hospital admissions. No past surgical operations. No previous
blood transfusions.

Px cannot recall if he completed his immunizations when he was a child.

Px had measles and mumps at 12 years old, and chickenpox at 20 years old. No other
childhood diseases such as asthma, whooping cough, scarlet fever, and dengue. Px has no
known food and drug allergies. No known psychiatric illnesses.
Family History

Personal and Social History

Patient E.R, was born and raised in San Remigio, Cebu, is a retired
timekeeper/ worker at a hacienda. He lives with her son and daughter at their fully cemented
house. He finished high school and a vocational course in automotive mechanics and
agriculture back then. Activities of daily living includes walking around the house and doing
some light household chores. Hobby includes watching television.

His usual diet includes fish, meats, and vegetables. He occasionally drinks
soft drinks about once in 2 weeks, and eats junk foods. He drinks a lot of water and can
consume about 3-4 L of water a day. He takes iron supplements. He urinates frequently (5-6
times a day), but his bowel movement is only two times a week. He sleeps at around 7pm,
and wakes up at around 6am. He never engaged into smoking. He started drinking when he
was in his 30’s, he can consume 3 glasses of Red Horse beer, but stopped drinking last 2016.
Review of Systems
General: there is gradual weight loss, fatigue, weakness. Patient is afebrile.
Skin: no itchiness, no wounds, no bruises.
Head: no headache, no history of head injury.
Eyes: no blurring of vision, no pain, no history of glaucoma and cataracts.
Ears: no hearing loss, no tinnitus, no pain, no discharge.
Nose and Sinuses: no colds, no stuffiness, no obstruction, no discharge, no pain.
Mouth and Throat: no bleeding gums, no pain during swallowing, no ulcers, no hoarseness.
Neck: no swollen lymph nodes, no pain.

Lymphatics: no swollen lymph nodes.
Breasts: no lumps, no masses, no pain, no nipple discharge.
Respiratory: no shortness of breath, no cough, no asthma, no history of exposure to TB.
Cardiovascular: No known heart disease; not hypertensive; no chest pain; no palpitations,
no rapid and shallow breathing, no difficulty of breathing on exertion, no difficulty of breathing
when lying down.
Gastrointestinal: Appetite is poor, no nausea, no vomiting, no indigestion, no diarrhea; has
abdominal pain 5/10.
Urinary: no dysuria, no hematuria or recent flank pain, no nocturia, no polyuria, no
incontinence, no history of kidney stones.

Genital Tract: no pain in the scrotum, no pelvic infections, no history of STI.
Peripheral Vascular: no intermittent claudication, no leg cramps, no varicose veins.

Musculoskeletal: no joint pains on both knees during cold weather, no arthritis, no gout, no
backache, no stiffness, no edema, no pain.

Neurologic: no fainting, no seizures, no paralysis, no numbness; no tremors.

Psychiatric: no anxiety, no depression, no nervousness, no irritability, no phobias.

Endocrine: no heat or cold intolerance, no known thyroid disorder, no excessive urination, no
delayed wound healing; no excessive sweating, thirst and hunger.

Hematological: No bleeding gums, no previous blood transfusions; no family history of
anemia.
Physical Examination
General: The patient was conscious, alert and coherent. He was oriented to time, place, &
person. He was cooperative when being asked. Patient was lying supine on bed, relaxed and
in no distress.
Vital Signs:
Blood pressure(Right Arm): 100/75 mmHg, supine position
HR: 60 bpm, right radial, supine position
RR: 16 cpm,
Temp (right axillary): 36.5C
Height: 172 cm
Weight: 59 kg
BMI: 19.9

Skin: skin is brown, warm to touch with good turgor. No central cyanosis. No ecchymoses,
petechiae or jaundice. Non-pruritus rashes on abdomen is present.

Head: normocephalic, no deformities, no fractures, masses or tenderness. Hair is of average

texture, evenly distributed. No lumps, no scars, scalp without lesions.

Eyes: no ptosis and exophthalmos. Eyelashes are pointed outward. Thin eyebrows. pink
conjunctiva, white sclera. pupils 4mm constricting to 2 mm, round, regular, equally reactive to
light. Extraocular muscle movements are intact.

Ears: both ears are symmetric with no masses and discharges. No tenderness on palpation
on both auricles and mastoid process.

Nose and Sinuses: nasal septum is midline, no sinus tenderness, no nasal discharge.

Mouth and Throat: tongue is midline, no soreness, no ulcers.

Neck: Trachea midline. No lumps or deformities.

Respiratory
Inspection: symmetrical chest expansion
Palpation: No palpable masses or crepitus noted. Normal tactile fremitus of anterior chest
Percussion: Lungs are resonant on all lobes.
Auscultation: Breath sounds vesicular, no rales or other adventitious sounds. No
Bronchophony, egophony or whispered pectriloquy.
Cardiovascular
Inspection: Symmetric with no suprasternal, subcostal or intercostal retractions. Apical
Impulse barely seen. JVP is 2 cm above sternal angle, taken at 30 degrees position.
Palpation: No heaves, lifts of thrills. Carotid upstrokes are brisk, no bruits. No tender areas or
masses. PMI located on the left 5th ICS midclavicular line.

Percussion: Cardiac dullness noted to the left of the sternum from 3rd-5th ICS

Auscultation: Rhythm is normal, timing is normal, no murmur. No thrills nor heaves. Prominent
S1 and S2, normal at both apex and base. No splitting of S2. Rate is normal and regular.
Gastrointestinal
Inspection: Abdomen symmetrical, scaphoid, No Bruises or erythema, no striae. No bulging of
umbilicus. Presence of purpura lesions.
Auscultation: Normoactive bowel sounds (8/min), no bruits or friction rub.
Percussion: (-)shifting dullness, No splenomegaly or hepatomegaly.
Palpation: No Pain felt upon superficial and deep palpation. No masses, no hepatomegaly
(Liver span:8cm right MCL, 5cm: MSL; normal liver edge (soft, sharp, and regular, with a
smooth surface), spleen and kidneys not felt. No CVA tenderness. (-) murphy sign, (-)
Rovsing sign.
Peripheral Vascular System: Extremities are warm. No peripheral edema, no varicosities or
stasis. No femoral or abdominal bruits.

Musculoskeletal: Full range of motion in all joints of extremities. No pain with flexion,
extension and rotation of joints. No Evidence of deformity. No crepitus, effusion or bony
enlargement.
Neurologic Examination
Mental Status: Patient is awake, cooperative, oriented to time, person, and place.
Glasgow Coma Scale:
Eye Opening = 4 : eyes open
Motor Response = 6 : follows simple commands
Verbal Response = 5 : converses and is oriented
Total = 15

CN 1 (Olfactory): Intact sense of smell on right and left nostrils.

CN 2 (Optic): Equal reaction to consensual and direct pupillary light reflex.
CN 3, 4, 6 (Oculomotor, Trochlear, Abducens): able to follow fixated object without eye
deviation.
CN 5 (Trigeminal): Sensory corneal reflexes present. Motor intact: Pterygoid and masseter
able to contract.
CN 7 (Facial): able to raise eyebrows and close both eyes tightly, can frown, can clench
teeth.
CN 8 (Vestibulocochlear): able to hear whispered voice in both ears, AC>BC.
CN 9, 10 (Glossopharyngeal, Vagus): not done
CN 11 (Accessory): not done
CN 12 (Hypoglossal): tongue is midline, pn resting and protrusion.

Motor: Good muscle bulk and tone. Strength in right and left biceps, triceps(4/5). Romberg’s
test not done.
Cerebellar: Patient was able to perform finger to nose test and good rapid alternating
rhythmic movements.
Sensory: Patient able to identify sensations to pain, pinprick, light touch, position and
vibration. Cortical discriminates intact with: graphesthesia.
Reflexes

Biceps Triceps Brachioradialis Patellar Achilles Plantar

RT 2+ 2+ 2+ 2+ 2+ 2+
LT 2+ 2+ 2+ 2+ 2+ 2+
Clinical Impression: Bleeding Peptic Ulcer Disease
Considerations: Patient Hx Findings
1. melena- if BPUD is untreated, causes UGI bleeding.

2. epigastric pain – burning sensation

3. Patient was prescribed with Kremil-S.

- antacids neutralize existing stomach acid and can provide rapid
pain relief.

4. Px was alcoholic.
- erosion from stomach acids.

Differential Diagnoses
1. Esophageal Varices
Rule In: Abdominal/Epigastric pain, Melena, History of alcoholism
Rule Out: Absence of ascites, Absence of painless hematemesis
2. Gastric cancer
Rule In: Black Tarry Stools(Melena), Abdominal Pain Radiating to the back
Rule Out: No History of hematemesis, No history of Dysphagia, odynophagia,
Bloating, Dyspepsia, No Palpable abdominal mass, No Enlarged lymph
nodes(Virchow) and (Irish), Absent Periumbilical mass (Sister Mary Joseph sign),
Absence of hematemesis. No early satiety.
 Confirm Rule Out with endoscopy is still
needed.
3. Peptic Ulcer Disease
Rule In: Black Tarry Stools (Melena), Abdominal (epifastric) Pain radiating to the back.

Diagnostic Modalities
1. CBC
2. Urea breath test
3. H. pylori antigen test in stool
4. CA 19-9
5. Biopsy
6. CT Scan, MRI, US
7. Endoscopy
8. Barium swallow
Treatment and Management
1. Anemia
Oral iron suffices most patients.
✔ Ferrous sulfate
• IV iron – for those who cannot tolerate oral iron.
• Blood transfusion for severe anemia.
-symptomatic and/or unstable patients, those with haemoglobin <7-8 g/dL
and those with continued/excessive blood loss.
2. Bleeding Peptic Ulcer Disease

Oral PPI (Proton pump inhibitor). No need for endoscopic treatment

- if EGD finding shows clean based ulcer and flat pigmented spots.

IV PPI +/- dual endoscopic treatment

- if EGD finding shows adherent clots covering ulcer base

IV PPI + dual endoscopic treatment

- if EGD finding shows sentinel clot and active spurting from an ulcer.

Standard PPI therapy: dosage

1. Omeprazole 20 mg BID
2. Lansoprazole 30 mg BID
3. Dexlansoprazole 30 mg BID
4. Esomeprazole 40 mg BID
5. Pantoprazole 40 mg BID
6. Rabeprazole 20 mg BID
Other considerations:
1. Therapeutic endoscopy (advantage of immediate treatment)
2. Surgery for intractable or recurrent bleeding
3. H. Pylori eradication if with evidence of infection
4. Avoidance of NSAIDs if feasible
First-line Therapy of H. pylori Infection:
1. Triple Therapy for 14 days
➢ For low Clarithromycin resistance areas (<15%resistance rates)
➢ For patients with no history of macrolide exposure for any reason

The three components include:

2. Bismuth-Based Therapy for 10-14 days (Quadruple Therapy)

➢ Used for areas with high clarithromycin and metronidazole resistance or those with
penicillin allergy
➢ Includes:
Bismuth subsalicylate 300 mg QID (or Bismuth subcitrate 120-300 mg QID), plus
Metronidazole 250 mg QID (or 500 mg TID to QID), plus
Doxycycline 500 mg QID

3. Non-Bismuth Quadruple Therapy for total of 10-14 days

(for high Clarithromycin resistance areas)