CASE CONFERENCE: Peptic Ulcer Disease. General Information J.D., 49 y/o, M Filipino, Roman Catholic...

CASE CONFERENCE:Peptic Ulcer Disease

General Information

• J.D., 49 y/o, M• Filipino, Roman Catholic• Married• Jeepney Driver• Chief Complaint: Abdominal Pain

HPI

13 years PTA

•Patient experienced gnawing, non-radiating pain, grade 2-3/10, in the RLQ•Relieved by the intake of antacids, aggravated by heavy meal intake•Sought consult at a local clinic, given Buscopan with unrecalled dosage

HPI

2 days PTA

•Patient experienced one episode of melena, no consult was done

HPI

7 hours PTA

• Patient experienced severe, non-radiating, epigastric pain, graded 9/10•Sought consult at a local clinic and was advised to take clarithromycin and omeprazole which afforded temporary relief

HPI

6 hours PTA

• Patient still experienced severe, non radiating, ‐epigastric pain, grade 9/10. The pain then became generalized all over the abdomen.•Due to persistence of symptoms, the patient was rushed to the USTH ER

Admission

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

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

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

PE Findings

• Abdomen– Flat, no scars or striae, NABS, tympani4c 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, 4ght sphincteric tone, smooth rectal mucosa, ( ) palpated masses, ( ) pararectal ‐ ‐tenderness, brown stool on tacta4ng finger

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 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

• Acute abdomen secondary to perforated viscus secondary to PUD

DISCUSSION

• Salient Features• PUD• ACUTE ABDOMEN

Differential Diagnosis

Plans

• CBC, U/A, Na, K, serum amylase and lipase• CXR, 12 L ECG‐• Emergency exploratory laparotomy, primary

repair with omental bumress

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

Lab Results: CBCDate 05/14/09 Results Ref. Range

HGBHCTPlateletWBCNeutLymph.

1360.41332 12.70.830.17

120-1700.37-0.54150 – 4504.5 – 10.000.50 – 0.700.20 – 0.40

Lab Results: UrinalysisDate 05/14/09ColorTransparencypHSp. GravityAlbuminSugarRBCWBC

Dark yellowSl. Turbid6.01.020Negative++0-3/hpf 0-3/hpf

Lab Results: Electrolytes

Date 05/14/09

Result Ref. Range

Sodium

Potassium

136

3.5

137-147

3.5-5.1

Lab Results: Serum Amylase and Lipase

Date 05/14/09 Results Ref. RangeAmylase 65.0 10-130 IIU/LLipase 31.8 13-60 IU/L

12-Lead ECG Result

• Done 05/14/09• Normal findings

CXT 5/13/09

CXR 5/13/09

• There is a linear lucency noted in the subdiaphragmatic area 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

• 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