1. U PPER GI C ASE Surgery 2

2. G ENERAL I NFORMATION J.D., 49 y/o, Male Filipino, Roman Catholic Married Jeepney driver CHIEF COMPLAINT: ABDOMINAL PAIN

3. H ISTORY OF P RESENT I LLNESS 13 Years PTA Patient experienced gnawing, non ‐ radiating pain, grade 2 ‐ 3/10, in the right lower quadrant Relieved by intake of antacids, aggravated by heavy meal intake. Sought consult at a local clinic, given Buscopan with unrecalled dosage 2 days PTA Patient experienced one episode of melena, no consult was done. 7 hours PTA Patient experienced severe, nonradiating, epigastric pain, graded 9/10 Sought consult at a local clinic and was advised to take clarithromycin and omeprazole which afforded temporary relief

4. 6 Hours PTA Patient still experienced severe, non ‐ radiating, epigastric pain, grade 9/10. The pain then became generalized all over the abdomen. Due to persistence of symptoms, the patient was rushed to the USTH ER. ADMISSION

5. S ALIENT F EATURES SubjectiveObjective Gnawing, non ‐ radiating pain, grade 2 ‐ 3/10, in the right lower quadrant Relieved by intake of antacids, aggravated by heavy meal intake One episode of melena Patient experienced severe, nonradiating, epigastric pain, graded 9/10 Took buscopan, clarithromycin and omeprazole Smoker (40 pack years) (+) melena (+) direct and rebound tenderness upper abdominal region No diarrhea, no constipation, no nausea, no vomiting, no heartburn BP 140/90

6. Pertinent Negatives no weight loss no diarrhea no constipation no nausea no vomiting no heartburn

7. P AST M EDICAL H ISTORY No hypertension, diabetes, or asthma No previous surgeries or transfusions

8. F AMILY H ISTORY ( ‐ ) asthma, DM, hypertension

9. P ERSONAL AND S OCIAL H ISTORY Smoker, 40 pack years Occasional alcoholic beverage drinker Diet: mixed Denies illicit drug use

10. R EVIEW OF S YSTEMS No fever, no weight loss, no weakness, no anorexia No rashes, no increased pigmentation No visual dysfunction, no redness, no itchiness, no eye pain, excessive lacrimation No deafness, no tinnitus, no aural discharge No epistaxis, no nasal discharge No gum bleeding, no throat soreness No dyspnea, no shortness of breath, no chest pain, no palpitations No diarrhea, no constipation, no nausea, no vomiting, no heartburn, (+) melena No dysuria, hematuria, incontinence No limitation of movements, joint pains and swelling of joints No heat or cold intolerance, no polyphagia, polydipsia, polyuria No convulsions, no headache, no sleep disturbances

11. P HYSICAL E XAM General – conscious, coherent, not in cardiorespiratory distress Vital Signs: – BP: 140/90 mmHg – PR = 90 bpm, regular – RR = 22 cpm – T = 37.6 ˚C Skin – Warm, moist – no active dermatoses

12. HEENT – pink palpebral conjunctivae, anicteric scelrae, no nasoaural discharge, moist buccal mucosa, tonsils not enlarged, non hyperemic posterior pharyngeal walls – Supple neck, no palpable cervical lymph nodes, thyroid not enlarged Thorax – symmetric chest expansion, ( ‐ ) retractions, resonant on both lung fields, equal and clear breath sounds Cardiovascular – Adynamic precordium, AB 5th LICS MCL, apex S1>S2, base S2>S1, ( ‐ ) murm

13. Abdomen – Flat, no scars or striae, NABS, tympanitic upon percussion, Traube’s space not obliterated, (+) direct and rebound tenderness upper abdominal region with guarding ( ‐ ) Rovsing’s sign, ( ‐ ) psoas sign DRE: – no skin tags seen, tight sphincteric tone, smooth rectal mucosa, ( ‐ ) palpated masses, ( ‐ ) pararectal tenderness, brown stool on tactating finger

14. Extremities – Pulses were full and equal, no cyanosis, no edema, no limitation of movement in all extremities were noted. Neurological Examination – Conscious, coherent, oriented to 3 spheres – Cranial nerves: pupils 2 ‐ 3 mm ERTL, EOMs full and equal, V1V2V3 intact, can clench teeth, can raise eyebrows, can close eyes tightly, can smile, can frown, can puff cheeks, no facial asymmetry, no hearing loss, can turn head from side to side with resistance, can shrug shoulders, tongue midline on protrusion

15. Neurologic Exam – Motor: MMT of 5/5 on all extremi4es – Cerebellar: can do FTNT & APST – DTR’s: ++ on all extremi4es – No sensory deficit – ( ‐ ) Babinski – ( ‐ ) nuchal rigidity

16. Assessment: Acute Abdomen secondary to perforated viscus secondary to PUD.

17. D IFFERENTIAL D IAGNOSES The list of gastrointestinal and non- gastrointestinal disorders that can mimic ulceration of the stomach or duodenum is quite extensive. Harrisons Principle of internal medicine, 17 th ed.

18. Several additional disease processes that may present with “ulcerlike” symptoms include proximal gastrointestinal tumors, gastroesophagealreflux disease (GERD), vascular disease, pancreaticobiliary disease (biliary colic,chronic pancreatitis), and gastroduodenal Crohn’s disease. Harrisons Principle of interal medicine, 17 th ed.

19. PATHOPHYSIOLOGIC BASIS OF PEPTIC ULCER DISEASE PUD encompasses both gastric and duodenal ulcers. Ulcers are defined as a break in the mucosal surface 5 mm in size, with depth to the submucosa. Harrisons Principle of interal medicine, 17 th ed.

20. A major causative factor (60% of gastric and up to 90% of duodenal ulcers) is chronic inflammation due to Helicobacter pylori that colonizes ( i.e. settles there after entering the body) the antral mucosa. The immune system is unable to clear the infection, despite the appearance of antibodies. Thus, the bacterium can cause a chronic active gastritis, resulting in a defect in the regulation of gastrin production by that part of the stomach, and gastrin secretion is increased Helicobacter pylori

22. C LINICAL F EATURES Very common in the united states = 4 million cases (new and reccurrence) per year Lifetime Prevalence = 12% in men, 10% in women 1,500 deaths/year due to complications Harrisons Principle of interal medicine, 17 th ed.

23. D IAGNOSTIC P ROCEDURES CBC: The normal HGB and HCT suggests the absence of anemia or blood loss. The high WBC count (in particular the neutrophils) suggests infection. Date05/14/09Reference Range HGB136120-170 HCT0.410.37-0.54 Platelet332150-450 WBC12.74.5-10.00 Neut0.830.50-0.70 Lymph.0.170.20-0.40

24. D IAGNOSTIC P ROCEDURES Urinalysis Values are unremarkable except for sugar, which is normally not found in the urine. The presence of sugar warrants further testing. Date05/14/09 ColorDark TransparencySI. Turbid pH6.0 Sp. Gravity1.020 AlbuminNegative Sugar++ 0-3

25. D IAGNOSTIC P ROCEDURES Serum Na and K Both values are within the normal reference range. Date05/14/09Ref. Range Sodium136137-147 Potassium3.53.5-5.1

26. D IAGNOSTIC P ROCEDURES Serum Amylase and Lipase The presence of severe acute abdominal pain indicates the testing of serum amylase and lipase. Since the values are unremarkable, acute pancreatitis is ruled out. Date05/14/09Ref. Range Amylase65.010-130 Lipase31.813-60

27. D IAGNOSTIC P ROCEDURES The 12-L ECG taken at 05/14/09 presents with normal findings. The ECG records the electrical activity of the heart over time via skin electrodes. The normal levels of serum sodium and potassium is also consistent with the normal ECG. This rules out the presence of cardiovascular involvement in the patient.

28. D IAGNOSTIC P ROCEDURES There is a linear lucency noted in the sub ‐ diaphragmatic area suggestive of pneumoperitoneum. The translucency suggests the presence of free gas in the peritoneal cavity This is an important finding in the diagnosis of perforation of the GI tract

29. D IAGNOSTIC P ROCEDURES The patient’s severe abdominal pain and tenderness is associated with pneumoperitoneum It is most commonly caused by a perforated abdominal viscus, usually due to a perforated peptic ulcer

30. D IAGNOSTIC P ROCEDURES A laparotomy is a surgical procedure involving an incision through the abdominal wall to gain access into the abdominal cavity.

31. D IAGNOSTIC P ROCEDURES In diagnostic laparotomy (also known as exploratory laparotomy), the disease nature is unknown, and laparotomy is deemed the best way to identify the cause.

32. Surgical Intervention The omental buttress is done in order to close the perforated peptic ulcer (‘omental patch repair’).

33. Pre and Post Op Care

34. Preoperative preparation *IV access is obtained and any fluid and electrolyte abnormalities are corrected - Hypokalemia = central venous line is required - Acidosis = fluid repletion and IV bicarbonate infusion *Foley Catheter bladder darinage to assess urine output. - Urine output = 0.5ml/kg/hr - BP = at leaat 100mmHg - PR = 100 bpm

35. Preoperative Preparation *Antibiotic Infusions are necessary - Gram-negative enteric organisms and anaerobes *Nasogastric tube for patients with paralytic ileus - Decrease likelihood of vomiting and aspiration *Preoperative transfusions are unnecessary since anemia is uncommon howerever patients should have been blood tyoed and crossmatched.

36. Pre-operative Preparation *Patient must not have anything to eat or drink after midnight on the night before you arrive at the hospital. *Patient should not take any aspirin or other anti-inflammatory for 10 days before surgery. Occasionally these drugs can interfere with the blood's ability to clot and can actually increase the amount of bleeding during and after surgery. *If the patient is in any medication - including over the counter drugs - be sure if the patient can continue taking that medication. And if not, how far in advance of surgery you must stop.

37. Post-op Care *Most patients experience at least some pain following surgery, but if properly handled, it shouldn't present any serious problems. *check on the patient – monitor the patients progress following surgery note any inflammations or infections on the site of surgery, complications may arise such as vomiting and diarrhea *Note if there is bleeding on the site of incision or any leaks in that matter *Look for any signs of infection near the incision - increased swelling, redness, bleeding or other discharge