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Upper GI Case

Upper GI Case. Surgery 2. General Information. J.D., 49 y/o, Male Filipino, Roman Catholic Married Jeepney driver CHIEF COMPLAINT: ABDOMINAL PAIN. History of Present Illness. ADMISSION. Salient Features. Pertinent Negatives. no weight loss no diarrhea no constipation no nausea

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Upper GI Case

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  1. Upper GI Case Surgery 2

  2. General Information • J.D., 49 y/o, Male • Filipino, Roman Catholic • Married • Jeepney driver • CHIEF COMPLAINT: ABDOMINAL PAIN

  3. History of Present Illness

  4. ADMISSION

  5. Salient Features

  6. Pertinent Negatives no weight loss no diarrhea no constipation no nausea no vomiting no heartburn

  7. Past Medical History • No hypertension, diabetes, or asthma • No previous surgeries or transfusions

  8. Family History • (‐) asthma, DM, hypertension

  9. Personal and Social History • Smoker, 40 pack years • Occasional alcoholic beverage drinker • Diet: mixed • Denies illicit drug use

  10. Review of Systems No fever, no weight loss, no weakness, no anorexia • No rashes, no increased pigmentation • No visual dysfunction, no redness, no itchiness, no eye pain, excessive lacrimation • No deafness, no tinnitus, no aural discharge • No epistaxis, no nasal discharge • No gum bleeding, no throat soreness • No dyspnea, no shortness of breath, no chest pain, no palpitations • No diarrhea, no constipation, no nausea, no vomiting, no heartburn, (+) melena • No dysuria, hematuria, incontinence • No limitation of movements, joint pains and swelling of joints • No heat or cold intolerance, no polyphagia, polydipsia, polyuria • No convulsions, no headache, no sleep disturbances

  11. Physical Exam General – conscious, coherent, not in cardiorespiratory distress • Vital Signs: – BP: 140/90 mmHg – PR = 90 bpm, regular – RR = 22 cpm – T = 37.6 ˚C • Skin – Warm, moist – no active dermatoses

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

  13. Abdomen – Flat, no scars or striae, NABS, tympanitic upon percussion, Traube’s space not obliterated, (+) direct and rebound tenderness upper abdominal region with guarding (‐) Rovsing’s sign, (‐) psoas sign • DRE: – no skin tags seen, tight sphincteric tone, smooth rectal mucosa, (‐) palpated masses, (‐) pararectal tenderness, brown stool on tactating finger

  14. 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 tightly, 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

  15. 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

  16. Assessment: Acute Abdomen secondary to perforated viscus secondary to PUD.

  17. Differential Diagnoses • The list of gastrointestinal and non-gastrointestinal disorders that can mimic ulceration of the stomach or duodenum is quite extensive. Harrisons Principle of internal medicine, 17th ed.

  18. Several additional disease processes that may present with “ulcerlike” symptoms include proximal gastrointestinal tumors, gastroesophagealreflux disease (GERD), vascular disease, pancreaticobiliary disease (biliary colic,chronic pancreatitis), and gastroduodenal Crohn’s disease. • Harrisons Principle of interal medicine, 17th ed.

  19. PATHOPHYSIOLOGIC BASIS OF PEPTIC ULCER DISEASE PUD encompasses both gastric and duodenal ulcers. Ulcers are defined as a break in the mucosal surface 5 mm in size, with depth to the submucosa. Harrisons Principle of interal medicine, 17th ed.

  20. A major causative factor (60% of gastric and up to 90% of duodenal ulcers) is chronic inflammation due to Helicobacter pylori that colonizes (i.e. settles there after entering the body) the antral mucosa. The immune system is unable to clear the infection, despite the appearance of antibodies. Thus, the bacterium can cause a chronic active gastritis, resulting in a defect in the regulation of gastrin production by that part of the stomach, and gastrin secretion is increased 

  21. Clinical Features • Very common in the united states = 4 million cases (new and reccurrence) per year • Lifetime Prevalence = 12% in men, 10% in women • 1,500 deaths/year due to complications Harrisons Principle of interal medicine, 17th ed.

  22. Diagnostic Procedures CBC: • The normal HGB and HCT suggests the absence of anemia or blood loss. • The high WBC count (in particular the neutrophils) suggests infection.

  23. Diagnostic Procedures Urinalysis • Values are unremarkable except for sugar, which is normally not found in the urine. The presence of sugar warrants further testing.

  24. Diagnostic Procedures Serum Na and K • Both values are within the normal reference range.

  25. Diagnostic Procedures Serum Amylase and Lipase • The presence of severe acute abdominal pain indicates the testing of serum amylase and lipase. • Since the values are unremarkable, acute pancreatitis is ruled out.

  26. Diagnostic Procedures • The 12-L ECG taken at 05/14/09 presents with normal findings. • The ECG records the electrical activity of the heart over time via skin electrodes. • The normal levels of serum sodium and potassium is also consistent with the normal ECG. • This rules out the presence of cardiovascular involvement in the patient.

  27. Diagnostic Procedures • There is a linear lucency noted in the sub‐diaphragmatic area suggestive of pneumoperitoneum. • The translucency suggests the presence of free gas in the peritoneal cavity • This is an important finding in the diagnosis of perforation of the GI tract

  28. Diagnostic Procedures • The patient’s severe abdominal pain and tenderness is associated with pneumoperitoneum • It is most commonly caused by a perforated abdominal viscus, usually due to a perforated peptic ulcer

  29. Diagnostic Procedures • A laparotomy is a surgical procedure involving an incision through the abdominal wall to gain access into the abdominal cavity.

  30. Diagnostic Procedures • In diagnostic laparotomy (also known as exploratory laparotomy), the disease nature is unknown, and laparotomy is deemed the best way to identify the cause.

  31. Surgical Intervention The omental buttress is done in order to close the perforated peptic ulcer (‘omental patch repair’).

  32. Pre and Post Op Care

  33. Preoperative preparation *IV access is obtained and any fluid and electrolyte abnormalities are corrected - Hypokalemia = central venous line is required - Acidosis = fluid repletion and IV bicarbonate infusion *Foley Catheter bladder darinage to assess urine output. - Urine output = 0.5ml/kg/hr - BP = at leaat 100mmHg - PR = 100 bpm

  34. Preoperative Preparation *Antibiotic Infusions are necessary - Gram-negative enteric organisms and anaerobes *Nasogastric tube for patients with paralytic ileus - Decrease likelihood of vomiting and aspiration *Preoperative transfusions are unnecessary since anemia is uncommon howerever patients should have been blood tyoed and crossmatched.

  35. Pre-operative Preparation *Patient must not have anything to eat or drink after midnight on the night before you arrive at the hospital. *Patient should not take any aspirin or other anti-inflammatory for 10 days before surgery. Occasionally these drugs can interfere with the blood's ability to clot and can actually increase the amount of bleeding during and after surgery. *If the patient is in any medication - including over the counter drugs - be sure if the patient can continue taking that medication. And if not, how far in advance of surgery you must stop.

  36. Post-op Care *Most patients experience at least some pain following surgery, but if properly handled, it shouldn't present any serious problems. *check on the patient – monitor the patients progress following surgery note any inflammations or infections on the site of surgery, complications may arise such as vomiting and diarrhea *Note if there is bleeding on the site of incision or any leaks in that matter *Look for any signs of infection near the incision - increased swelling, redness, bleeding or other discharge

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