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Primary Care Case *Dyspepsia*

Primary Care Case *Dyspepsia*. Ventura, Rolando Jr. Verdolaga , Ria Mae Villanueva, Maureen Elvira Villanueva, Roel Visperas , Joana Francesca. Background. Dyspepsia is a term used to describe a constellation of symptoms arising from the upper abdomen .

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Primary Care Case *Dyspepsia*

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  1. Primary Care Case*Dyspepsia* Ventura, Rolando Jr. Verdolaga, Ria Mae Villanueva, Maureen Elvira Villanueva, Roel Visperas, Joana Francesca

  2. Background • Dyspepsia is a term used to describe a constellation of symptoms arising from the upper abdomen. • It is a subjective feeling most often described by patients as “upper abdominal discomfort”, “pain”, “aching”, “bloatedness”, “fullness”, “burning” or “indigestion”.

  3. General Data • B.T. • 51/M, Married • Tayuman, Manila • Driver • CC: Epigastric Pain (“sinisikmura”, “dumidighay”)

  4. History of Present Illness 2 months PTC 2 months PTC: • throbbing epigastric pain • pain severity of 8/10 • associated with loss of appetite, dizziness and nausea • pain temporarily relieved by intake of food • sought consult at a private clinic • hepatitis titersand CXR were normal • diagnosis of Urinary Tract Infection based on urinalysis

  5. History of Present Illness 2 months PTC 2 months PTC: Ultrasound findings: • Hepatic Masses • 2.09 x 1.8 x 1.8 cm Right Lobe • 1.26 x 1.12 x 1.08 cm Left Lobe • 8.33 x 6.45 x 6.35 cm Caudate Lobe • Impression: • Hepatic New Growth • Gallbladder polyp • Suspect: para-aortic node enlargement • Spleen, kidneys, urinary bladder, prostate normal

  6. History of Present Illness 2 months PTC 3 weeks PTC 3 weeks PTC: • consulted a different private clinic regarding persistence of symptoms. • tumormarker was requested • prescribed Tramadol HCl 50 mg • self-medicating with Mefenamic Acid and Herbal medication for the kidneys (Uniherb Kidney Care).

  7. History of Present Illness 2 months PTC 3 weeks PTC 1 week PTC 1 week PTC: • patient noted tarry stools (melena) • 1 episode of blood-streaked stool (minimal) • patient also noted recurrence of pain on the left lower quadrant radiating to the back

  8. History of Present Illness 2 days PTC 2 months PTC 3 weeks PTC 1 week PTC 2 days PTC • tumormarker levels showed normal AFP levels • prescribed with Omeprazole 20mg OD for 3 weeks • patient was then referred to PGH for liver biopsy.

  9. Review of Systems • (+) weight loss • 6% in 2 months • (+) loss of appetite • (-)fever • (-) chills • (-) headache • (-) blurring of vision • (-) hematemesis • (-) hemoptysis • (+) exertionaldyspnea • (-) Orthopnea • (-) PND • (-) chest pain • (+) nocturia • (-) frothy urine • (-) dysuria • (-) hematuria • (-) retention • (-) polyphagia • (-) polydipsia • (-) polyuria • (+) melena • (-) hematochezia

  10. Past Medical History • Pneumonia with pleural effusion- 1999 • Chicken pox- 2008 • No allergies

  11. Personal/Social History • Former smoker (20 pack-years) • stopped in 1996 • Occasional alcoholic beverage drinker • History of illicit drug use • Marijuana: 1982-2000, occasional • Shabu: 1984-1999, occasional • Has had 3 sexual partners before marriage, non-promiscuous • Diet: usually eats fish, vegetables and fruits. Does not eat beef/pork often

  12. Family History

  13. Psychosocial Impact of Illness Patient was deeply worried by the cost of diagnostic procedures and treatment • However, when probed on the financial capability to have the needed tests done, he shared that he may be able to get support from his employer. • He was also referred to Medical Social Services for financial support. Px was also worried about the presence of liver masses on ultrasound and worries that it may be an indication of a malignancy.

  14. Physical Examination • Awake, alert, cooperative, not in cardiorespiratory distress • BP: 110/80 • PR: 80 beats per minute • RR: 16 breaths per minute • Temperature: 35.6 degree Celsius • BMI: 30

  15. Physical Examination • HEENT • pink conjunctivae • icteric sclerae • trachea is midline • (-) nasoaural discharge • (-) neck vein engorgement • (-) cervical lymphadenopathy • (-) anterior neck mass

  16. Physical Examination • Chest/Lungs • equal chest expansion • clear breath sounds • no adventitious breath sounds • (-) wheezes • (-) crackles • (-) rhonchi

  17. Physical Examination • CVS • normal rate and rhythm • distinct S1 and S2 • no murmurs • Abdomen • Distended • hyperactive bowel sounds • tenderness on the epigastric, periumbilical and hypogastricareas on light and deep palpation • Liver span 6cm

  18. Physical Examination • Genitourinary • no pain on kidney punch • Digital rectal exam • no blood on examining finger • prostate not enlarged • no masses • good sphincter tone

  19. Physical Examination • Skin/ Extremities • pink nail beds • full and equal pulses • (-) edema • (-) cyanosis • Muscle strength normal on all 4 extremities

  20. Differential Diagnosis

  21. Differential Diagnosis

  22. Differential Diagnosis

  23. Differential Diagnosis

  24. Differential Diagnosis

  25. Assessment • Peptic Ulcer Disease • t/c Malignancy with liver metastasis • t/c Urinary Tract Infection (uncomplicated cystitis) • Other: Obesity grade 2

  26. Clinical Pathway of Uninvestigated Dyspepsia Patient present with recurrent epigastric pain and/or post prandial fullness for > 2 weeks Do biopsychosocial history and complete PE No Burning sensation radiating upward? Yes Manage as GERD No Manage as NSAID induced Gastritis Yes Regular NSAID use No

  27. No Manage organic pathology Consider organic pathology? Yes No Uninvestigated dyspepsia Yes Determine presence of alarm feature Refer to a specialist for possible EGD Dyspepsia w/o alarm symptoms No

  28. Continue PPI OR increase dose OR add pro kinetics for 4 weeks Lifestyle advice and psychosocial intervention Follow-up after 4 weeks No Yes No further treatment Symptoms resolved? Empiric therapy for 2 weeks 1st line - PPI Alternative: H2RA, prokinetics, antacids Lifestyle advice and psychosocial intervention Follow-up after 2 weeks

  29. No further treatment H. Pylori test (+)? Yes Yes No Symptoms resolved? Eradication Treatment PPI (increased dose) +prokinetics for 4 weeks Follow-up after 4 weeks No Yes H. Pylori test feasible? No Empiric Eradication Symptoms resolved? No Yes No further treatment Refer to a specialist for possible EGD

  30. Plan • Diagnostics • PUD: Referral to Gastrointestinal Clinic for Endoscopy, culture gastric contents for H.pylori, tissue biopsy of ulcer/s (if present) • Abdominal CT-Scan with contrast • Labs: • CBC, Platelet, Pt/Ptt • FBS • BUN, Creatinine • LFT, Bilirubin • Urinalysis, Urine culture

  31. Plan • Therapeutic • Pharmacological • Continue Omeprazole 20 mg OD before breakfast • Tramadol HCl 50mg every 4 hours for the pain • Non-Pharmacological • Stop self-medication with Mefenamic Acid (NSAID use) • Avoid intake of alcoholic beverages, coffee, sour and spicy food • Avoid stress • Do not skip meals

  32. Plan • For Obesity: • Labs: Lipid profile • -low cholesterol diet • Regular exercise • Reduced intake of salty food and sweets

  33. Plan • Follow up after 10 days for analysis of imaging results and evaluation of response to Omeprazole.

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