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IMS Case 4

IMS Case 4. Personal Details. Name: Mr. CYH Age: 60 years old Race: Chinese Gender: Male. He came to SOPD for his follow-up appointment on Helicobacter pylori eradication treatment. Chief Complaint. History of Presenting Illness.

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IMS Case 4

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  1. IMS Case 4

  2. Personal Details • Name: Mr. CYH • Age: 60 years old • Race: Chinese • Gender: Male

  3. He came to SOPD for his follow-up appointment on Helicobacter pylori eradication treatment. Chief Complaint

  4. History of Presenting Illness • One month ago, patient complained of localized pain at epigastric region, the pain was gnawing in nature, severity grade 6. The pain usually comes in the morning and during midnight, aggravated by hunger and mildly relieved after meal. • He said he felt “wind” in the stomach, he has lost some appetite. • no remarkable weight lost; no complaints of vomiting, dysphagia, diarrhoea or constipation, but he only able to pass little motion and sometimes he experience tenesmus. • His urination was normal, and his bowel habit slightly decreased. • He denied any previous episode of similar kind of pain.

  5. History of Presenting Illness • Endoscopy done shows multiple punch-hole lesions at the antrum of stomach without centre ulceration indication of H. pylori infection. • Clo test performed confirmed positive H. pylori infection. • He was then prescribed three medication for the infection: • C. Amoxicillin 1gm BD • C. Clarithromycin 500mg BD • C. Pantoprazole 40mg BD for 1 / 52

  6. History of Presenting Illness • During the follow-up episode, patient comment that his epigastric pain was subsided. • However, he described that he experienced multiple episodes of diarrhoea during the past one week.

  7. History of Presenting Illness • Doctor explained that the diarrheoa was drug-induced diarrhea, he advised the patient to continue the medications for one more week before further evaluation.

  8. Final Diagnosis • Drug-induced diarrhoea due to antibiotic-associated colitis due to Clarithromycin for Helicobacter pylori eradication treatment

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