Case Pres1

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CASE PRESENTATION

East Avenue Medical Center

Female Surgical WardGroup D

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Background of the case:Upper Gastrointestinal

bleeding refers to

hemorrhage in the upper

gastrointestinal tract. Theanatomic cut-off for

upper GI bleeding is the

ligament of Treitz, which

connects the fourthportion of the duodenum

to the diaphragm near the

splenic flexure of the

colon.

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FAMILY HISTORY

Ô Father had a stroke.

Ô Patients paternal uncle was operated in the

esophagus of unknown reason and that currently

patient had no voice.

Ô No known heredo-familial diseases such as BA,

PTB, DM, or Cancer.

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OB HISTORY

Ô G2P2 (2002)

Ô Menarche at 12 years old

Ô Consuming 2 pads a day

Ô Menstruation last from 5-6 days duration

Ô Regular monthly interval

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DIETARY HISTORY

Ô Patient not taking any vitamins as Vit C

Ô fond of salted foods

Ô fond of smoked foods

Ô fond of canned foods

Ô (+) smoker

Ô (+) alcohol drinker

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PAST MEDICAL HISTORY

Ô As above, not known to have DM, BA, PTB,

HPN, or Cancer.

Ô No previous hospitalization, surgeries, or

allergies to foods and medications.

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HISTORY OF PRESENT ILLNESS

Ô 5 months PTA ² patient had epigastric pain radiating to

the back, relieved by food but eventually recurs 2-3 hours

after associated with early satiety, greenish LBM of 4

episodes a day approximately ½ cup per episode that

lasted for 3 days. Patient self-medicated with

Loperamide to relief self of LBM. Patient also noted

gradual weight loss approximately 40%. Consult done at

Health Center and was prescribed with antacid takenTID for 2 weeks with relief of symptoms.

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Ô 1 ½ month PTA ² Patient started to have 4-5 times

vomiting usually occuring in the late afternoon with

persistent epigastric pain and heartburn.

Ô 5 weeks PTA ² With persistence of symptoms, patient

consulted to a private MD and was told that she has

gastritis. Given Xeloid Gel, TID, Gasmed tab TID and

Omeprazole 20mg OD with relief. But 1 week later, the

symptoms recurred after the patient completed her

medications.

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Ô 2 weeks PTA ² Patient consulted at TALA Hospital and

was prescribed with Omeprazole OD, Maalox 1tbsp QID

and Ofloxacin 200mg BID for 1 week for her UTI.

Ô 3 days PTA ² Patient had coffee ground post prandial

vomiting occuring 5 times a day with anorexia, epigastric

pain but no melena. Self treated with Maalox 1tbsp OD

and Omeprazole 20mg OD. Persistence prompted

consult hence admission.

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Ô Blood Pressure: 90/60 mmHg

Ô Cardiac Rate: 90 bpm

Ô Respiratory Rate: 22 cpm

Ô Temperature: 37.1°c

Ô Height: 1.55m

Ô Weight: 45 kg

Ô BMI: 18.75 kg/m2

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HEENT:

Ô Pale palpebral conjunctiva

Ô Anicteric sclera

Ô No nasoaural discharge

Ô No tonsillopharyngeal congestion

Ô Noted eyes to be slightly protruded

Ô (+) Coffee Ground output per NGT

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NECK:

Ô Supple

Ô No neck vein engorgement

Ô No palpable lymphadenopathies

Ô (-) supraclavicular

Ô Lymphadenopathy

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HEART:

Ô Adynamicprecordium

Ô Apex beat at 5th ICS MCL

Ô Regular heart rate

Ô No murmur

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ABDOMEN:

Ô Flat and soft

Ô (+) ovoid fixed non mobile smooth mass atepigastric area with tenderness

Ô Normoactive bowel sound

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EXTREMITY:

ÔNo gross deformity

ÔFull and equal pulses

ÔNo edema

Ô Pale nail beds

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DRE:

Ô (+) skin tag at anus

Ô Good sphincter tone

Ô Empty rectal vault

Ô Smooth wall with no mass

Ô Noted dark brown stool per examining finger

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ROS:

Ô (-) orthopnea

Ô (-) easy fatigability

Ô (-) palpitations

Ô (-) PNO

Ô (-) chest pain

Ô (-) chest discomforts

Ô (-) diarrhea

Ô (-) constipation

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Assessment: Upper Gastrointestinal Bleeding

probably secondary to:

1. BPUD

2. Bleeding Gastric mass

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CYTOLOGY REPORT

DIAGNOSIS:

Gastric mucosa, biopsy:

Ô Gastric Adenocarcinoma

Ô Poorly differentiated with signet ring features

Ô Negative for Helicobacter pylori

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SPECIMEN: Gastric

mucosa

CLINICAL

DIAGNOSIS

AND HISTORY:

Ô Upper

gastrointestinal

bleeding probably

secondary togastric mass

probably

malignant

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GROSS AND MICROSCOPIC

DESCRIPTION:

Ô Rectered specimen labeled ́ gastric

mucosaµ consist of 8 cream-white-

black, irregular, soft tissue

fragments.

Ô Sections show gastric tissues with

involvement of a neoplasm seen in

sheets.

Ô No Helicobacter pylori organisms

are evident on Giemsa stain.

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GASTRIC ADENOCARCINOMA

Ô It is also called malignant tumor of the stomach.

Ô Risk factors include: chron

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LABORATORY RESULTS

HEMATOLOGY

COMPONENTS R ESULT NOR MAL

VALUES

SI UNITS

Hemoglobin 70 120-140 for female

adults

gm/L

Hematocrit 0.210 0.38-0.48 for

female adults

gm/L

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ANATOMY AND PHYSIOLOGY

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PATHOPHYSIOLOGY

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DRUG STUDY

ÔAminoleban 500cc

ÔOmeprazole 40mgÔFerrous Sulfate (TID) P.O

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Nursing Care Plan

Case Pres1

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