PAMANTASAN NG LUNGSOD NG MAYNILA College of Medicine
RELOJ, JERNELYN P. Medicine IIIB rd 3 Ward work 03 November 2006
Date of Interview: 27 October 2006 Informant: Patient and wife Reliability: 75%
General Data R.S., is a 58 year old male, married, Filipino, Catholic, driver, and presently residing in Paranaque, was nd admitted for the 2 time at Ospital ng Maynila Medical Center on October 26, 2006. Chief Complaint Generalized body weakness History of Present Illness 4 weeks PTA, R.S. felt dizzy upon standing up. According to him, this symptom occurred almost everyday, but he did not seek consult nor take any medication since it was relieved by rest. He also noticed that his stool have become darker and described it as dinuguan-like in color. The patient denies having fever, anorexia, abdominal pain, vomiting, and diarrhea. 3 weeks PTA, the patient suddenly experienced blurring of vision and lightheadedness. He fell down, but did not loss consciousness. The patient vomited and he characterized it as clear white, bitter, and 30-60 ml in amount. For the succeeding days, the patient had weakness, pallor, and loss of appetite. No consult was done and no medications were taken. 2 weeks PTA, weakness, pallor, and loss of appetite persisted and the patient had to stop working because of this. However, the patient still did not seek consult nor take any medication to abate the symptoms. 1 week PTA, the above-mentioned symptoms persisted. Aside from this, the patient also had burning abdominal pain in the epigastric area shortly after eating a bulk of lanzones. The abdominal pain was relieved after the patient self-medicated with Hyoscine (Buscopan) 10 mg tablet. 2 days PTA, the patient consulted a private clinic and he was advised to have his lab taken. The remarkable findings were increased fasting blood sugar (FBS) and decreased hemoglobin (Hgb). The patient, however, could not recall the exact values. On the day of the consult, the above-mentioned symptoms progressed. The patient then decided to seek consult and was subsequently admitted. Past Medical History R.S. underwent cholecystectomy due to gall stones at the Ospital ng Maynila Medical Center in 1997. He has unrecalled immunizations. He had measles and mumps during childhood, but apparently has no allergies to food or drugs. Family History His father died due to colon cancer, age unrecalled. His mother is living, but is diagnosed to have diabetes mellitus and hypertension. All his siblings are apparently healthy. He is married for 39 years. He has 4 sons who are apparently healthy. Personal/Social History R.S. finished only high school. He works as a driver for 23 years now. He is a smoker of 34 pack years. He is a non-alcoholic beverage drinker and denies use of prohibited drugs. He eats regularly, 3x a day and prefers fatty foods and sweets. He has no regular exercise. He takes multivitamins (Centrum) and food supplements (Charantia and Marvel Taheebo). He lives in a bungalow-type concrete apartment with his wife and 2 sons. They have their own comfort room. They use distilled drinking water and NAWASA for their everyday use. Garbage is collected regularly. The neighborhood is not congested.
Review of Systems CONSTITUTIONAL: With weight loss (20 lbs in 2 weeks), no fever, no chills, no night sweats INTEGUMENT: Skin No rashes, no pruritus, no bruising, no change in color; Hair no hair loss, no abnormal hair growth HEENT: Head No headaches, no injury, no tenderness; Eyes Use of glasses, no blurring, no diplopia, no pain, no inflammation, no discharge; Ears No changes in hearing, tinnitus, pain, discharge, dizziness; Nose No allergies, no obstruction, no polyps, no changes in or loss of sense of smell, no discharge, no sneezing, no epistaxis; Throat No mouth sores, no hoarseness, no ulcerations or other lesions on tongue, gums, and buccal mucosa CARDIAC: No palpitation, no orthopnea, no paroxysmal nocturnal dyspnea, no precordial pain, no edema, no substernal pain, no cyanosis RESPIRATORY: No cough, no dyspnea, no chest pain, no wheezing, no hemoptysis GENITO-URINARY: Has Nocturia, 3x/night, 200-250ml, clear, light yellow; no urinary retention, no dysuria, no hematuria, no polyuria, no oliguria, no urinary incontinence, no urethral discharge HEMATOLOGIC: No easy bruising, no history of transfusion reaction, no bleeding gums, no epistaxis NEUROMUSCULAR: No memory loss, no tremors, no nervousness, no convulsions, no insomnia MUSCULOSKELETAL: No tenderness, no cramps, no pain, no joint swellings, no stiffness ENDOCRINE: has polydipsia, no polyuria, no polyphagia, no cold and heat intolerance, no palpitations, no sluggishness, no hoarseness Physical Examination GENERAL SURVEY: R.S. is alert, lying supine in bed, not in respiratory distress, IV line on L arm, conscious of time, place and person and is cooperative. BP: 120/70 mmHg RR: 16 cpm PR: 74 bpm TEMP: 36.6˚C Height: 5’8” (172.3 cm) Weight: 130 lbs (59.1 kg) 2 BMI: 20.4 kg/m SKIN: Brown complexion, no jaundice, no sores, no bruises, no rashes, no nodules HEAD: Normal contour and configuration with no unusual depressions, no tenderness, fine hair texture, no masses. EYES: Anicteric sclerae, pink palpebral conjunctivae, no lid lagging, eyelashes directed outward, pupils are normal and equal in size (about 2-3 mm), extraocular muscles intact, visual field examination normal. EARS: No deformities, no auditory canal discharge, no tenderness, no hearing impairment, intact tympanic membrane on both ears. NOSE: No swellings, no discharge, no nasal obstruction, septum symmetrical and at midline. MOUTH AND THROAT: Dry lips, full dentures, no bleeding gums, no pharyngeal erythema, no exudates, pale mucosa NECK: Symmetrical, no limitation of range of motion, no tenderness, no dilated neck veins, JVP at 9 cm at 30º, no palpable lymph nodes, thyroid not palpable, carotid upstrokes are brisk without bruits. THORAX AND LUNGS: The thorax is symmetrical. The anteroposterior (AP) diameter is lesser than transverse diameter. There is symmetrical chest expansion, no retractions, no chest lag, no mass, no tenderness. Vocal and tactile fremiti are equal in both lung fields. Resonant sound on all lung fields. Breath sound is vesicular. HEART: Carotid upstrokes are brisk, without bruits. The PMI is palpated medial to the left th midclavicular line at the 4 intercostal space; absence of murmur ABDOMEN: Abdomen is flat with an 11 cm surgical scar noted at the RUQ area; with soft bowel sound (5 bowel sound per minute); no areas of tenderness; liver span is 8 cm EXTREMITIES: Full equal pulses both in upper and lower extremities, no mass, no spasticity, no rigidity, no edema. No clubbing of nails, pale nailbeds. NEUROLOGIC EXAMINATION: Mental Status Examination The patient is oriented to time, place and person. He was able to recall immediate, recent and remote information. No problems with repetition noted. He is able to name accurately all objects presented and was able to read, write and copy figures without difficulty.
Cranial Nerve Examination
I II Able to identify odor of alcohol with both nostrils. Visual field is full by confrontation. Able to read third line of Jaeger’s Chart at a distance of 14 inches on both eyes. (+) Direct and consensual light reflexes on both eyes, No strabismus, no deviation, no ptosis. Extraocular muscle movements are intact. Sensory function: Able to perceive light touch in both sides of the face. Motor function: Symmetrical and good temporal and masseter muscle contraction. Able to raise eyebrows, close eyes, smile, frown, show teeth and puff out cheeks. Able to hear rubbing fingers at a distance of 2 inches. (+) Gag reflex; No dysphonia, no dysarthia, uvula not deviated. Muscular movements of trapezius and SCM are intact; Able to elevate both shoulders against resistance; Able to move face from side to side. Tongue is in midline; Able to protrude and move tongue symmetrically.
III, IV, VI V
VII VIII IX, X XI XII
Motor System Examination 4/5 4/5 Strength of both right and left UE and LE is 4/5; complete firm resistance; no fasciculations and involuntary movements 4/5 4/5
Sensory System Examination 100% 100% Positive graphesthesia, stereognosis, point localization, 2-pt discrimination; 100% intact sensation on both UE & LE as to pinprick, light touch & pressure
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Legend: ++++ +++ ++ + 0 -
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Hyperreflexia with clonus Hyperreflexia without clonus Normoflexia Hyporeflexia Areflexia
Biceps Reflex: flexion of the arm at the elbow, 2+ grading Triceps Reflex: extension of the arm at the elbow, 2+ grading Brachioradial Reflex: extension of the hand at the wrist, 2+ grading Patellar reflex: extension of the leg, 2+ grading Ankle reflex: plantar flexion, 2+ grading Babinski Reflex: Absent
Patient’s Salient Features 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Weakness Lightheadedness (presyncope) Pallor Anorexia Melena Abdominal pain Decreased Hgb Family history of cancer Increased FBS Nocturia Polydipsia Family history of diabetes mellitus
1. Upper Gastrointestinal Bleeding secondary to Peptic Ulcer Disease 2. To consider, Diabetes Mellitus
Generally, the patient presented with nonspecific symptoms such as weakness and anorexia. However, because of the blood loss, and the symptoms which are suggestive of anemia (pallor, lightheadedness, and decreased hemoglobin), upper gastrointestinal bleeding is considered. Upper gastrointestinal bleeding leads to blood loss. It can be presented as melena, hematemesis, hematochaezia and symptoms of anemia. In the case of the patient, melena and symptoms of anemia were the manifestations. Due to the deficiency in hemoglobin, decreased oxygen delivery to tissues follows thus leading to hemodynamic instability. In the case of the patient, this was manifested as weakness, lightheadedness, and pallor. Upper gastrointestinal bleeding has multifactorial etiologies. The most common to which is peptic ulcer disease (PUD). PUD is considered primarily because of the abdominal pain the patient experienced after meal. He characterized it as burning in quality and located in the epigastric area. This is also consistent with PUD. Moreover, patients with bleeding ulcers may give a history of melena or episodes of presyncope, which holds true for the patient. PUD is a condition to which there is an inflammatory injury in the mucosa, submucosa, or muscularis mucosa of the stomach or duodenum. The inflammatory injury develops when the aggressive factors (gastric acid and the proteolytic enzyme pepsin) overcome the protective mechanism (mucous layer, bicarbonate secretion, and protective prostaglandins) in the stomach or duodenum. Any process that increases gastric acidity, decreases prostaglandin production (such as chronic use of NSAIDs), or interferes with the mucous layer (such as Helicobacter pylori infection) can cause such an imbalance and leads to peptic ulcer disease. In the case of the patient, since he denies chronic NSAID usage, the etiologic factor may be H. pylori. This is due to the fact that H. pylori infection is the most common cause of PUD (accounting for about 70% of cases), the prevalence of infection is higher among older age group and male gender, and cigarette smoking is a risk factor. It is not definite yet whether the patient has gastric or duodenal ulcer, since the two cannot be differentiated based on clinical history alone. Due to nocturia, polydipsia, increased FBS, and a family history of DM, the patient may possibly have DM as a separate disease entity. Differential Diagnoses DUODENAL ULCER As previously mentioned, duodenal ulcer is considered primarily because of the burning epigastric pain. As in the patient, the discomfort is described as ill-defined and aching sensation. Aside from this, active gastrointestinal blood loss is also a feature of DU and this is present in the patient, which was manifested as melena. However, in duodenal ulcer, abdominal pain occurs hours after food intake and is relieved by antacids or food. This was not the case of the patient. Moreover, the patient also has no epigastric tenderness, which is the most frequent finding in patients with PUD. GASTRIC ULCER As what is stated a while ago, gastric ulcer could not be differentiated from duodenal ulcer on the basis of clinical history alone. So basically, gastric ulcer is ruled in for the same reason – due to the presence of burning epigastric pain and melena which represents blood loss. However, one feature that distinguishes GU from DU is the timing of abdominal pain. In GU, pain occurs shortly after a meal, and this is the case of the patient. Moreover, weight loss, which is very evident in the patient, is also more common in GU than in DU. This differential, however, is ruled out also for the same reason – there is no tenderness in the epigastric area of the abdomen.
GASTRINOMA Gastrinoma is a gastrin-secreting tumor that is most commonly found in the duodenum. Enormous secretion of gastrin from the tumor cells leads to hyperplasia of fundic parietal cells and increased basal acid secretion. This results in severe ulcer disease. Gastrinoma is considered primarily because the symptoms of this disease mimic that of peptic ulcer disease. Usually, abdominal pain occurs and symptoms that relate to a complication of PUD, such as bleeding, develop, such is the case of the patient. Weight loss, which also occurred with the patient, may also be attributed to acid hypersecretion. However, in gastrinoma, the most frequent abnormal finding in physical exam is epigastric tenderness. This is not found in the patient. Furthermore, gastroesophageal reflux, diarrhea and steatorrhea are not manifested by the patient. Diagnosis and Management Because of the poor predictive value of abdominal pain for the presence of a gastroduodenal ulcer and the multiple disease processes that mimic this disease, the presence of an ulcer must be established. Hence, radiographic (barium study) or endoscopic procedure is requested. Barium studies of the proximal gastrointestinal tract are commonly used as a first test for documenting an ulcer. Typically, the DU appears as a well-demarcated crater, most often seen in the bulb. A gastric ulcer may represent benign or malignant disease. A benign GU also appears as a discrete crater with radiating mucosal folds originating from the ulcer margin. Ulcers >3 cm in size are more often malignant. However, sensitivity of barium studies when it comes with GU is low, hence, radiographic studies that show a GU must be followed by endoscopy or biopsy. Endoscopy provides the most sensitive and specific approach for examining the upper gastrointestinal tract. This is particularly useful because it facilitates photographic documentation of a mucosal defect and tissue biopsy, which rules out malignancy or H. pylori. Furthermore, it accurately identify too small lesions and can determine if an ulcer is a source of blood loss. Tests for the detection of H. pylori is also requested. The biopsy urease test is a simple and rapid test with specificity and sensitivity of 90-95%. However, if endoscopy is not necessary, urea breath test which is also simple and rapid, could be performed instead. Routine laboratory exam such as CBC is also requested to establish presence of anemia. The patient may have decreased erythrocytes, hemoglobin and hematocrit. ECG is also required because there may be anemiarelated ischemic changes. As for the suspected DM, diagnosis is obtained by requesting the following: random blood glucose concentration, or fasting plasma glucose or two-hour plasma glucose during an oral glucose tolerance test. The table below depicts the criteria for the diagnosis of diabetes mellitus Symptoms of diabetes plus random blood glucose concentration ≥ 11.1 mmol/L (200 mg.dL) or Fasting plasma glucose ≥ 7.0 mmol/L (126 mg/dL) on two separate occasions or Two-hour plasma glucose ≥ 11.1 mmol/L (200 mg/dl) during oral glucose tolerance test (following ingestion of 75 gm of glucose at 2 hours post-prandial and at least one other occasion)
After establishing the diagnosis with the aid of the afore-mentioned procedures, management and choice of therapeutic drugs are as follows: For the upper gastrointestinal bleeding secondary to peptic ulcer disease: 1. Diet: a. Avoid foods that stimulate acid secretion. b. Stop smoking and alcohol. 2. Gastric Ulcer: a. If urease test (-), treat with: H2-blockers or Proton-pump inhibitors +/- Antacids for 6-8 weeks or H2-blockers or Proton-pump inhibitors +/- Sucralfate for 6-8 weeks b. If urease (+) or if H. pylori positive: give Eradication Treatment (refer to #4) c. Repeat endoscopy or do Upper GI series after 4-8 weeks of medical treatment. If there is no improvement, suspect malignancy.
3. Duodenal Ulcer: a. If urease test (-): Treat with H2-blockers +/- Sucralfate +/- Antacids or Proton-pump inhibitors for 4 weeks b. If urease test (+) or if H. pylori positive: give Eradication Treatment (refer to #4) c. If with frequent, recurrent or severe duodenal ulcer or if with duodenal ulcer complication: give maintenance dose of H2-blocker or proton-pump inhibitor (1/2 of daily dose) or re-check H.pylori eradication. If still urease (+), may give another eradication treatment. 4. Helicobacter pylori Eradication Treatment: a. Proton-pump inhibitor (PPI) to be given BID PO x 1 week + Amoxicillin 500 mg 2 caps BID x 1 week + Clarithromycin 500 mg 1 tab BID x 1 week Note: For PPI, one may use any of the following: Esomeprazole 40 mg tablet Omeprazole 20 mg capsule Lansoprazole 30 mg capsule Pantoprazole 40 mg tablet Rebeprazole 10 mg tablet b. PPI to be given BID PO x 1 week (as above) + Metronidazole 500 mg 1 tab BID x 1 week + Clarithromycin 500 mg 1 tab BID x 1 week 5. Symptomatic Medications: a. Pain: Hyoscine-N-butylbromide (Buscopan) 1 amp IV q 6 hrs PRN or Ketorolac (Toradol) or Tramadol (Tramal) IV b. Vomiting: Metoclopromide (Plasil) 1 amp IV q 8 hrs PRN
For the management of DM, appropriate diet and regular exercise is advised. Oral hypoglycemic agent is prescribed and the choice is as follows: a. b. c. d. e. Sulfonylureas (Glipizide or Glibenclamide) Add Binguanides if still uncontrolled (Metformin 500 mg tab TID) Add Alpha-glucoside inhibitor if with post-prandial hyperglycemia (Acarbose 50-100 mg tab TID) Add Thiazolidinediones (Rosilitazone 4-8 mg tab OD) Shift to insulin treatment if still uncontrolled with oral hypoglycemic agents