Santiago. See. Siy. Sotalbo. Soyangco. Tagayona. Tagomata. Talan. The Case of N.I. Santiago. See. Siy. Sotalbo. Soyangco. Tagayona. Tagomata. Talan.

General Information NI, 64/M from Gen. Trias, Cavite Chief Complaint: epigastric pain Abdominal pain

Triage Findings Vital Signs (1/10/13 2:50 PM) Classification: emergent BP: 90/50 PR: 80 RR: 22 Temp: 36.8 Classification: emergent

Reason for Classification Patient is experiencing Hypotension, possibly explained by melena, a sign of upper GI bleeding, for a duration of six days already Life-threatening => Emergent => Immediate evaluation and treatment

Primary Survey Circulation Hypotensive No active bleeding Normal HR Airway Patent Breathing Non-dyspneic Disability No neurologic deficits GCS 15 Pain VAS 5/10

Initial Intervention/Resuscitation IVF 1L pNSS x fast drip given

Secondary survey

History of Present Illness 3 weeks prior to admission (+) epigastric pain, “nangangasim at kumikirot,” intermittent, non-radiating, unrelieved by food intake (+) consulted at a local MD and was given unrecalled medications In the interim, patient noted no relief or progression in the pain despite good compliance

6 days prior to admission (+) passage of dark-colored stools, around 1 cup, 2-3x a week, (+) anorexia, (+) weight loss, (+) weakness, still without relief of epigastric pain 1 day prior to admission (+) increase in weakness, (+) melena 3x a day, (+) consulted at a local MD, CBC done: Hgb of 83, prompting consult at PGH

ROS General (-) fever HEENT (+) headache, (-) dizziness Respiratory (+) cough with yellowish sputum, (-) difficulty of breathing GIT/GUT (+) abdominal pain (-) vomiting, alternating diarrhea/constipation (-) dysuria, tea-colored urine (-) irregular bowel movement, (-) dec. in stool caliber (-) jaundice Skin/Extremities (-) jaundice, cyanosis

Past Medical History (-) DM, HTN, PTB, asthma, allergy (+) history of NSAID use (mefenamic acid) for body aches (+) PUD, 2010, maintained on omeprazole 40 mg OD, poor compliance (+) s/p colonoscopy (2010, DLSUMC Cavite): N findings

Family Medical History No similar condition No history of CA, PTB, DM, HPN

Personal and Social History Patient is a smoker for ~40 pack-years Patient is an alcoholic-beverage drinker for ~30 years, stopped 20 years ago

Physical Examination General Survey: ambulatory, awake, conscious, not in distress Vital Signs: BP: 90/60 PR: 86 RR: 18 T: 36.8 HEENT: pale PC, anicteric sclerae (-) CLAD, ANM; clear output per NGT Chest: symmetric chest expansion, clear BS (-) retraction CVS: Adynamic precordium, NRRR, (-) murmur

Abdomen: soft, distended, (+) guarding (+) direct tenderness on epigastric (-) ascites/ palpable masses DRE: good sphincter (-) palpable masses (+) black tarry stools per finger Extremities: good pulses, pale NB, (-) edema,cyanosis

Differentials PUD Gastritis (+) previous history of PUD (+) history of chronic NSAID use (+) epigastric pain (+) melena Most common cause of upper GI bleeding Table form Only 3 differentials Cannot be ruled out PUD/gastritis? Gastritis

Differentials Mallory-weiss tears Bleeding esophageal varices (+) melena (+) epigastric pain But (-) hematemesis, (-) vomiting, (-) history of alcohol intake But no history of liver disease or signs of portal hypertension Gastric CA But no constitutional symptoms such as weight loss, anorexia

Primary working impression Hypotension, resolved Probably secondary to upper gastrointestinal bleeding probably secondary to 1. BPUD 2. NSAID-induced Anemia secondary to upper GI bleed

Diagnostics

Diagnostics Blood tests CBC Blood typing and crossmatching Na, K, Cl PT/PTT BUN Crea Blood glucose Include actual diagnostics done for the patient and rationale for each, Include explanation of BUN/Crea ratio in relation to UGIB Include actual diagnostics done for the patient and rationale for each, Include explanation of BUN/Crea ratio in relation to UGIB

Management Include management done at the ER and rationale for each, correlate with the patient e.g. NGT, and why was it done; omeprazole what is it and why was it given Include management done at the ER and rationale for each, correlate with the patient e.g. NGT, and why was it done; omeprazole what is it and why was it given

discussion Please correlate

Benign Peptic Ulcer Disease

Background Defined as a painful mucosal erosion equal to or greater than 0.5 cm. Mostly involve only the mucosal lining 70 to 90% of PUDs are associated with H. pylori The duodenum is 4x likely to develop an ulcer than the stomach itself Retrieved from Pubmed Health (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001255/)

Risk Factors The ff raise your risk for peptic ulcer: Consuming too much alcohol Prolonged/regular use of NSAIDs Smoking or chewing tobacco Being in an immuno-compromised state Prolonged use of a mechanical ventilator Having undergone radiation therapy Retrieved from Pubmed Health (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001255/)

Symptomatology Common symptoms experienced by PUD patients are: Pain of discomfort in the epigastric area Arousing abdominal pain at night Nausea (vomiting sometimes relieves symptoms) Hunger/feeling of an empty stomach Feeling of fullness Retrieved from Pubmed Health (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001255/)

Pathophysiology PGE gastric duodenal epith. cells inc. mucus prod. inc. bicarbonate production inc. acid buffering capability resistance to acid and pepsin + tight intercellular junctions, mucosal blood flow, cellular restitution, and epithelial renewal resistance to ulcer formation

Pathophysiology PGE gastric duodenal epith. cells inc. mucus prod. inc. bicarbonate production inc. acid buffering capability resistance to acid and pepsin + tight intercellular junctions, mucosal blood flow, cellular restitution, and epithelial renewal resistance to ulcer formation H. Pylori Inflammation

Pathophysiology PGE gastric duodenal epith. cells inc. mucus prod. inc. bicarbonate production inc. acid buffering capability resistance to acid and pepsin + tight intercellular junctions, mucosal blood flow, cellular restitution, and epithelial renewal resistance to ulcer formation H. Pylori Inflammation H. Pylori Inc. acid prod.

Pathophysiology PGE gastric duodenal epith. cells inc. mucus prod. inc. bicarbonate production inc. acid buffering capability resistance to acid and pepsin + tight intercellular junctions, mucosal blood flow, cellular restitution, and epithelial renewal resistance to ulcer formation H. Pylori Inflammation H. Pylori Inc. acid prod. COX NSAIDs

Peptic ulcer Disease/Perlstent M.D. http://www.medicineclinic.org/AmbulatorySyllabus4/NEW%20peptic%20ulcer%20disease.htm

Treatment Algorithm Taken from http://www.aafp.org/afp/2007/1001/p1005.html

Ethical Considerations and Recommendations The patient’s chief complaint was epigastric pain. What was done to relieve this?

Ethical Considerations and Recommendations The patient came in pale, tachycardic. CBC revealed hemoglobin of 38. An order was given for transfusion of pRBC. After how many hours was the patient finally transfused?