PBL CASE2
Renji Hospital affiliated to Shanghai Jiaotong
University
TUTORIAL 1
PAGE 1
Mr. Wang, a 64-year-old male, presented with nausea and coffee ground emesis in
your department. In the past 1 month, he suffered from recurrent epigastric pain
accompanied with bloating, belching and anorexia.
1. What the key symptoms were presented in this case?
2. What are the possible etiologies and the associated pathogenesis of these
symptoms.
3. For the definite diagnosis, what more details should you ask the patient, such as
any risk factors, characteristics of these symptoms and any accompanying
symptoms?
TUTORIAL 1
PAGE 2
According to Mr. Wang’s complaint, he had been suffering from recurrent epigastric
burning pain accompanied with bloating, belching and anorexia for 1 month, but
without weight lose. After an episode of hematemesis (about 200 ml coffee ground
emesis) accompanied with weakness and dizziness, he came to your department. The
patient did not vomit vigorously before hematemesis. There was no history of alcohol
abuse or intake of NSAIDs, nor experience of surgery or trauma. He also denied the
history of acute or chronic viral hepatitis.
1. According to the presentation ,what is the most possible diagnosis?
2. What kinds of examination should you recommend to Mr. Wang?
TUTORIAL 1
PAGE 3
Physical examination: Temperature: 37.6℃, Blood Pressure: 90/60mmHg.
The patient looks pale. There is no jaundice of his skin and sclerae. No signs of
bleeding on his skin. Neither spider nevi nor liver palms are found. Superficial lymph
nodes are not palpable. The heart rate is 96 per minute with regular rhythm, without
any murmur. Chest auscultation: normal sounds, no rales. The abdomen is flat and
soft; no dilated vein; no visible intestinal pattern and peristaltic wave. There is mild
tenderness beneath the xiphoid process, without muscle guarding and rebound
tenderness. There are no palpable liver, spleen or other masses. There is no shifting
dullness. Bowel sounds are heard 8 per minute. There is no edema in the lower
extremities.
1. Could you find any clues from above information that might benefit for your
diagnosis?
2. Which following examinations should you order for the patient:
- Occult bleed test of vomitus or stool
- Blood routine test
- Liver function test
- Heptic virus
- Chest X ray
- Abdominal ultrasound
- emergency gastroscopy
3. What should you do before emergency gastroscopy?
TUTORIAL 2.
PAGE 1
Mr.Wang came back 3 hours later. The results are as follows:
1. Occult bleed test of vomitus: ++++
2. WBC 11.5*109/L；RBC350*1012/L；Hb 80g/L；PLT: 12*109/L
3. Liver function test: Normal
4. Heptic virus: HbsAg (-)
5. Abdominal ultrasound: Fatty liver; the gallbladder wall is slightly thickened; the
spleen and pancreas have a normal shape and size.
6. Emergency gastroscopy: Gastric angular ulcer; Chronic gastritis; Hp +
1. What’s your final diagnosis according to the above information?
2. How would you treat Mr. Whang?
3. Would you order any more examinations for the patient?
TUTORIAL 2 .
PAGE 2.
You treat the patient with antacids (proton pump inhibitor), hemostasis, arrange volume
replacement with crystalloid and colloid, and manage the other supportive and symptomatic treatment.
1. What is the biochemical and pharmacological mechanism for the therapy?
2. How will you further therapy the patient after the bleeding stopped?
TUTORIAL 2
PAGE 3
After 5 hours treatment, the patient had two black stools (about 500ml totally) without
vomiting. He felt tachycardia, dizziness and thirst.
1、What examinations should you manage for him now?
2、How to treatment him then?