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A case of a 66 year old female presenting with hematochezia Capili * Dagang *Dayrit* Golepang

A case of a 66 year old female presenting with hematochezia Capili * Dagang *Dayrit* Golepang. General data. Pt is a 66 year old female from _______ ( kuya Jas, alala mo kung taga saan siya ?) . Chief Complaint. Hematochezia. History of Present Illness. History of Present Illness.

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A case of a 66 year old female presenting with hematochezia Capili * Dagang *Dayrit* Golepang

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  1. A case of a 66 year old female presenting with hematochezia Capili*Dagang*Dayrit*Golepang

  2. General data • Pt is a 66 year old female from_______ (kuya Jas, alala mo kung tagasaansiya?)

  3. Chief Complaint • Hematochezia

  4. History of Present Illness

  5. History of Present Illness

  6. REVIEW OF SYSTEMS • (-) fever, cough, headache, nausea and vomiting,hematemesis • (-) chest pain, dyspnea,orthopnea • (-) acholic stool, tea-colored urine • (-) abdominal pain • (-) dysuria, hematuria • (-) diarrhea, constipation • (-) polyuria, polydipsia, polyphagia

  7. Past Medical History • s/pcholecystectomy for cholecystolithiasis– 2000 • (+) PTB – 2000, treatment completed but no repeat sputum exam or CXR was done • (-) HPN, DM, BA, allergies

  8. Family Medical History • Unremarkable

  9. Personal Social History • Non-alcoholic beverage drinker, non-smoker • Housewife • Non-promiscuous • No history of previous blood transfusions

  10. PHYSICAL EXAMINATION VITAL SIGNS: BP 80/50, HR 112, RR 20, drowsy HEENT: Pale Conjunctivae, IctericSclerae, (-) CLAD, (-) NVE, (-) ANM CHEST: ECE, CBC, (-) crackles/wheezes HEART: (-) heaves/thrills, ECE, tachycardic, (-) murmurs

  11. PHYSICAL EXAMINATION ABDOMEN: distended, (-) caput medusae, NABS, (-) tenderness, hepatosplenomegaly difficult to assess, (-) CVA tenderness DRE: GST, intact rectal vault, (+) palpable hemorrhoids at 6 o’clock and 9 o’clock, (+) blood PEF EXTREMITIES: pale nail beds, FEP, (-) edema, (-) palmarerythema, (-) asterixis

  12. Course in the ER • 5/21: seen in the ER with BP 80/50 HR 112 RR 20, (+) pale conjunctivae, (+) enlarged abdomen • FC was done and BP improved to 90/50 but dropped back to 70/50 • Pt was started on DopaDrip at 10 microgtts/min • NGT was inserted and showed bloody output per NGT • Pt was referred to Gen Med • A> Shock probably hypovolemic, secondary to GI losses; UGIB secondary to 1. BEV, 2. BPUD, CLD probably secondary to 1. Hepatobiliary TB, 2. Biliarycirrhosis secondary to hepatolithiasis; PTB IV; s/pcholecystectomy (2000) • Pt was transfused with 3 upRBC and 6 uFFP

  13. Course in the Wards • 5/22: Admitted to W1B18. Dopamine drip downtitrated 5 microgtts/min mainaining BP > 90/60 • RIC: NPO for now. IVF: D5 NSS 1L x 16, Tx: Omeprazole 40mg Q12, Metronidazole 750mg/tab TID, Myrin P 3 tabs OD, Lactulose 30cc OD at HS, Vitamin K 10mg/vial IV OD. Pt for BT of 4 u FFP now then 2 uQ12 and 1 upRBC PTXM x 4 hours. • Pt referred to GI for EGD

  14. Course in the Wards • 5/25: EGD done c/o GI. Results showed 4 columns of large tortuous varices with red walls. CE junction, cardia, fundus, and body of the stomach normal. Antrum with polypoidmasses partially obscuring the view of the pylorus. Duodenal bulb and second part of the duodenum not visualized. Post endoscopic diagnosis: esophageal varices, gastric polypoid mass. P> for RBL and biopsy of mass.

  15. Course in the Wards • RIC: Start Propanolol 10mg TID, Start Ceftriaxone 2 g IV OD. Decrease Opmeprazole to 40mg/vial IV OD. Continue Vit K, HRZE, Lactulose, Metronidazole. • WAPOD: referred for DOB while on 2ndu of FFP. STAT ECG was done showing: RSR, NA, PRP. (+) crackles on B LF. Pt given Furosemide 40mg IV bolus. Pt noted to be unresponsive w/o spontaneous respirations. Code called. ACLS done. Pt intubated ET size 7.5 level 22, 3 amps Epinephrine given, revived after 9 mins. Given 80 meqs NaHCO3 in 250 cc D5W x 24h for metabolic acidosis.

  16. Course in the Wards • 5/26: On PE: (+) retractions on L upper chest. On CXR: ET tube in R mainstem bronchus, (+) hazy infiltrates on B LF, (+) rib fracture A> ARF secondary to pulmonary congestion/TRALI, Encephalopathy, probably HIE (s/p CP arrest of 9 mins)

  17. Course in the Wards • For the next 3 days, pt was maintained on MV and inotropes. Could not be weaned off the ventilator. Could not down titrate and discontinue inotropes • Pt’s relatives signed a DNR. Pt eventually expired.

  18. Final Diagnosis • Encephalopathy prob HIE (s/p CP arrest 9 minutes) • Acute respiratory failure sec to pulmonary congestion • UGIB sec to BEV • CLD sec to • 1.hepatobiliay TB • 2. biliarycirrhosis • w/ portal HPN • Acute Pyelonephritis • HAP

  19. Possible Cause of Death

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