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General Data

General Data. Age: 45 year old Sex: male Chief Complain: Severe Abdominal Pain. History of Present Illness. Crampy , epigastric pain Relieved by food intake or antacids Melena UGI endoscopy: Erosive Gastritis Unrecalled medications. 3 years PTA. Epigastric pain Melena

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General Data

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  1. General Data • Age: 45 year old • Sex: male • Chief Complain: Severe Abdominal Pain

  2. History of Present Illness • Crampy, epigastric pain • Relieved by food intake or antacids • Melena • UGI endoscopy: Erosive Gastritis • Unrecalled medications 3 years PTA • Epigastric pain • Melena • Self‐medicated: Omeprazole 1 year PTA

  3. History of Present Illness A few hours PTA • Severe epigastric pain ADMISSION

  4. Past Medical History (-) HPN (-) DM Family History (-) Cancer Personal History • 10 pack‐years smoking • Drinks alcoholic beverage for 8 years

  5. Review of Systems (-) Weightloss (-) Dizziness (-) Chestpain

  6. Physical Examination • Conscious, coherent, in distress • BP= 140/90, PR= 105/min, RR=26/min ,T= 37.8 C • Warm moist skin, no active dermatoses • Pink palpebral conjunctivae, anictericsclerae • Heart and Lungs: regular rate and rhythm, clear breath sounds • Abdomen : flat, hypoactive bowel sounds, 􂈗 guarding and tenderness on all quadrants • DRE: brown stool on tactating finger

  7. Salient Features Pertinent Objective • PR= 105/min, RR=26/min • Abdomen : flat, hypoactive bowel sounds, (+) guarding and tenderness on all quadrants • DRE: brown stool on tactating finger Pertinent Subjective • 45 y/o • Crampy, epigastricpain, relieved by food intake or antacids • Melena • UGI endoscopy: Erosive Gastritis • 10 pack‐years smoking • Drinks alcoholic beverage for 8 years

  8. Clinical Impression • Perforation due to PUD

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