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roque alejandro CA

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									OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: ROQUE, Alejandro Age/sex: 73/M Address: 1123 Kagitingan, Tondo Manila Date of Admission: July 1, 2007 Admitting Diagnosis: UGIB probably secondary to (1) PUD (2) Malignancy PTB IV Residents-in-charge: Drs. Dalanon/ Gutierrez/ Gregorio Clerks-in-charge: Velasco/Velasco/ Viar Clinical Abstract GENERAL DATA This is a case of 73-year-old male who was brought in due to passage of black stool.

Hospital Number: 1705024

HISTORY OF PRESENT ILLNESS: Three days prior to admission, the patient started to pass out black stools associated with abdominal pain, epigastric in location, relieved by intake of Ranitidine. He also had generalized body weakness, pallor, dizziness and occasional dyspnea. No chest pain. No consult was done. On the day of admission, persistence of above symptoms prompted consult at the nearby hospital. He was advised to transfuse packed RBC but due to lack of blood, he was referred to this institution. Hence consult and subsequent admission. PAST MEDICAL HISTORY: (+) Ulcer 10-20 years ago s/p EGD ?Ulcer (+) UGIB – March/April 2007 s/p BT of 4 units PRBC (+) Chronic intake of Mefenamic Acid (-) HPN, DM, CVD, Bronchial asthma, allergies FAMILY MEDICAL HISTORY: (-) known heredofamilial diseases PERSONAL and SOCIAL HISTORY: Previous smoker, previous alcoholic beverage drinker REVIEW OF SYSTEMS: Constitutional: No fever, had weight loss, no chills, no loss of appetite Skin: no pallor, no rashes, without jaundice Respiratory: no colds, no hemoptysis Cardio: no chest pain, no palpitations, no PND, no orthopnea, no easy fatigability GUT: no oliguria, no hematuria, no nocturia Endo: no polyuria, polydipsia, polyphagia, Hema: no easy bruisability, no poor wound healing Musculoskeletal: no myalgia, no athralgia PHYSICAL EXAMINATION: Patient is conscious, coherent, not in cardiorespiratory distress Vital signs: BP: 100/60 mmHg RR : 18 cycles / minute HR : 80 beats / minute Temp : 36.7 º C (axillary)

Skin: No jaundice, poor skin turgor HEENT: anicteric sclera, pale palpebral conjunctiva, no naso-aural discharge, no cervical lymphadenopathy, no tonsillopharyngeal congestion, no neckmass, no neck vein engorgement Chest: Symmetric chest expansion, no lagging, no retractions, clear breath sounds Heart: Adynamic precordium, NRRR, PMI at 5th ICS LMCL, no murmurs Abdomen: flat, normoactive bowel sounds, no mass, (+) tenderness on epigastric area Extremities: Grossly normal, no cyanosis, no jaundice, full and equal pulses DRE: Good sphincter tone, no skin tags/ tissues / hemorrhoids, no masses, no tenderness, (+) greenish stools on examining finger, no blood on examining finger ASSESSMENT: UGIB probably secondary to (1) PUD (2) NSAID-induced Gastropathy (3) Malignancy PTB IV PLAN: For admission

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