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

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

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

4. 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

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

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

7. Secondary survey

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Diagnostics

20. 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

21. 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

22. discussion
Please correlate

23. Benign Peptic Ulcer Disease

24. 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 (

25. 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 (

26. 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 (

27. 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

28. 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

29. 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.

30. 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

31. Peptic ulcer Disease/Perlstent M.D.

32. Treatment Algorithm
Taken from

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

35. 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?