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CASE CONFERENCE: Peptic Ulcer Disease. General Information. J.D., 49 y/o, M Filipino, Roman Catholic Married Jeepney Driver Chief Complaint: Abdominal Pain. HPI. HPI. HPI. HPI. Admission. History. Past medical History (-) HPN, DM, Asthma (-) previous surgeries or BT Family History

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Case conference peptic ulcer disease

CASE CONFERENCE:Peptic Ulcer Disease


General information
General Information

  • J.D., 49 y/o, M

  • Filipino, Roman Catholic

  • Married

  • Jeepney Driver

  • Chief Complaint: Abdominal Pain





Case conference peptic ulcer disease
HPI

Admission


History
History

  • Past medical History

    • (-) HPN, DM, Asthma

    • (-) previous surgeries or BT

  • Family History

    • (-) HPN, DM, Asthma

  • Personal and Social History

    • Smoker (40 pack yrs)

    • Occasional alcoholic beverage drinker

    • Diet: mixed

    • Denies illicit drug use


Case conference peptic ulcer disease
ROS

  • No fever, no weight loss, no weakness, no anorexia

  • No rashes, no increased pigmenta4on

  • No visual dysfunc4on, no redness, no itchiness, no eye pain, excessive lacrima4on

  • No deafness, no 4nnitus, no aural discharge

  • No epistaxis, no nasal discharge

  • No gum bleeding, no throat soreness

  • No dyspnea, no shortness of breath, no chest pain, no palpita4ons

  • No diarrhea, no cons4pa4on, no nausea, no vomi4ng, no heartburn, (+) melena

  • No dysuria, hematuria, incon4nence

  • No limita4on of movements, joint pains and swelling of joints

  • No heat or cold intolerance, no polyphagia, polydipsia, polyuria

  • No convulsions, no headache, no sleep disturbances


Pe findings
PE Findings

  • General

    – conscious, coherent, not in cardiorespiratory distress

  • Vital Signs:

    – BP: 140/90 mmHg

    – PR = 90 bpm, regular

    – RR = 22 cpm

    – T = 37.6 oC

  • Skin

    – Warm, moist

    – no active dermatoses


Pe findings1
PE Findings

  • HEENT

    – pink palpebral conjunc4vae, anicteric scelrae, no nasoaural discharge, moist buccal mucosa, tonsils not enlarged, nonhyperemic posterior pharyngeal walls

    – Supple neck, no palpable cervical lymph nodes, thyroid not enlarged

  • Thorax

    – symmetric chest expansion, (‐) retrac4ons, resonant on both lung fields, equal and clear breath sounds

  • Cardiovascular

    – Adynamicprecordium, AB 5th LICS MCL, apex S1>S2, base S2>S1, (‐) murmurs


Pe findings2
PE Findings

  • Abdomen

    – Flat, no scars or striae, NABS, tympani4c upon percussion, Traube’sspace not obliterated, (+) direct and rebound tenderness upper abdominal region with guarding (‐) Rovsing’ssign, (‐) psoas sign

  • DRE:

    – no skin tags seen, 4ght sphincteric tone, smooth rectal mucosa, (‐) palpated masses, (‐) pararectaltenderness, brown stool on tacta4ng finger


Pe findings3
PE Findings

  • 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 slightly, 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.


Pe findings4
PE Findings

  • 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


Clinical assessment
Clinical Assessment

  • Acute abdomen secondary to perforated viscus secondary to PUD


Discussion
DISCUSSION

  • Salient Features

  • PUD

  • ACUTE ABDOMEN



Plans
Plans

  • CBC, U/A, Na, K, serum amylase and lipase

  • CXR, 12 L‐ECG

  • Emergency exploratory laparotomy, primary repair with omentalbumress


Patient s course in the ward
Patient’s Course in the Ward

  • 5/14/09

    – Admimed to MSW

    – Requested for CBC, U/A, CXR, Na, K, 12 L‐ECG, serum amylase and lipase

    – Scheduled for OR on the same day






12 lead ecg result
12-Lead ECG Result

  • Done 05/14/09

  • Normal findings



Cxr 5 13 09
CXR 5/13/09

  • There is a linear lucency noted in the subdiaphragmaticarea suggestive of pneumoperitoneum

  • Suspicious infiltrates are seen in the right apex and right infraclavicular area.

  • The heart is not enlarged

  • The right hemidiaphragm is slightly elevated

  • Sulci are intact


Post op
Post-op

  • Findings

    – 1x1.5 cm perfora4on at the anterior por4on of the 1st part of the duodenum and minimal amount of purulent peritoneal fluid noted

  • Patient was given D5 NR

  • Patient was put on pantoprazole 40 mg/IV OD and sulperazone (sulbactam+cefoperazone) 1.5 g/IV q8 hours