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CASE CONFERENCE: Peptic Ulcer Disease

CASE CONFERENCE: Peptic Ulcer Disease. General Information. J.D., 49 y/o, M Filipino, Roman Catholic Married Jeepney Driver Chief Complaint: Abdominal Pain. HPI. HPI. HPI. HPI. Admission. History. Past medical History (-) HPN, DM, Asthma (-) previous surgeries or BT Family History

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CASE CONFERENCE: Peptic Ulcer Disease

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  1. CASE CONFERENCE:Peptic Ulcer Disease

  2. General Information • J.D., 49 y/o, M • Filipino, Roman Catholic • Married • Jeepney Driver • Chief Complaint: Abdominal Pain

  3. HPI

  4. HPI

  5. HPI

  6. HPI Admission

  7. History • Past medical History • (-) HPN, DM, Asthma • (-) previous surgeries or BT • Family History • (-) HPN, DM, Asthma • Personal and Social History • Smoker (40 pack yrs) • Occasional alcoholic beverage drinker • Diet: mixed • Denies illicit drug use

  8. ROS • No fever, no weight loss, no weakness, no anorexia • No rashes, no increased pigmenta4on • No visual dysfunc4on, no redness, no itchiness, no eye pain, excessive lacrima4on • No deafness, no 4nnitus, no aural discharge • No epistaxis, no nasal discharge • No gum bleeding, no throat soreness • No dyspnea, no shortness of breath, no chest pain, no palpita4ons • No diarrhea, no cons4pa4on, no nausea, no vomi4ng, no heartburn, (+) melena • No dysuria, hematuria, incon4nence • No limita4on of movements, joint pains and swelling of joints • No heat or cold intolerance, no polyphagia, polydipsia, polyuria • No convulsions, no headache, no sleep disturbances

  9. PE Findings • General – conscious, coherent, not in cardiorespiratory distress • Vital Signs: – BP: 140/90 mmHg – PR = 90 bpm, regular – RR = 22 cpm – T = 37.6 oC • Skin – Warm, moist – no active dermatoses

  10. PE Findings • HEENT – pink palpebral conjunc4vae, anicteric scelrae, no nasoaural discharge, moist buccal mucosa, tonsils not enlarged, nonhyperemic posterior pharyngeal walls – Supple neck, no palpable cervical lymph nodes, thyroid not enlarged • Thorax – symmetric chest expansion, (‐) retrac4ons, resonant on both lung fields, equal and clear breath sounds • Cardiovascular – Adynamicprecordium, AB 5th LICS MCL, apex S1>S2, base S2>S1, (‐) murmurs

  11. PE Findings • Abdomen – Flat, no scars or striae, NABS, tympani4c upon percussion, Traube’sspace not obliterated, (+) direct and rebound tenderness upper abdominal region with guarding (‐) Rovsing’ssign, (‐) psoas sign • DRE: – no skin tags seen, 4ght sphincteric tone, smooth rectal mucosa, (‐) palpated masses, (‐) pararectaltenderness, brown stool on tacta4ng finger

  12. PE Findings • 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 slightly, 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.

  13. PE Findings • 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

  14. Clinical Assessment • Acute abdomen secondary to perforated viscus secondary to PUD

  15. DISCUSSION • Salient Features • PUD • ACUTE ABDOMEN

  16. Differential Diagnosis

  17. Plans • CBC, U/A, Na, K, serum amylase and lipase • CXR, 12 L‐ECG • Emergency exploratory laparotomy, primary repair with omentalbumress

  18. Patient’s Course in the Ward • 5/14/09 – Admimed to MSW – Requested for CBC, U/A, CXR, Na, K, 12 L‐ECG, serum amylase and lipase – Scheduled for OR on the same day

  19. Lab Results: CBC

  20. Lab Results: Urinalysis

  21. Lab Results: Electrolytes

  22. Lab Results: Serum Amylase and Lipase

  23. 12-Lead ECG Result • Done 05/14/09 • Normal findings

  24. CXT 5/13/09

  25. CXR 5/13/09 • There is a linear lucency noted in the subdiaphragmaticarea suggestive of pneumoperitoneum • Suspicious infiltrates are seen in the right apex and right infraclavicular area. • The heart is not enlarged • The right hemidiaphragm is slightly elevated • Sulci are intact

  26. Post-op • Findings – 1x1.5 cm perfora4on at the anterior por4on of the 1st part of the duodenum and minimal amount of purulent peritoneal fluid noted • Patient was given D5 NR • Patient was put on pantoprazole 40 mg/IV OD and sulperazone (sulbactam+cefoperazone) 1.5 g/IV q8 hours

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