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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Bongcaras, Benita Age/Sex: 60/F Address: 3111-G A. Bautista St. Punta Sta. Ana Manila Date of admission: August 21, 2007 Admitting Diagnosis: UGIB prob 2 to PUD HCVD CAD NSR II-B DM type 2 s/p EGD Final Diagnosis: UGIB 2 to Duodenal Ulcer HCVD CAD NSR II-B DM type 2 s/p EGD s/p cholecystectomy Residents in charge: Drs.Dalanon/Gutierrez/Gregorio CIC: Palay/Rentillo/Roxas

Hospital #: 1725439

Patient Discharge Summary This is a case of a 60 year-old female who came in to IM-ER due to passage of black tarry stools History of Present Illness Patient is a diagnosed case of PUD s/p EGD last week, no home meds given. Patient was apparently well until… 1 day PTA, patient had passage of black tarry stool about 250ml 3x. No noted hematemesis nor hematochezia. This was associated by easy fatigability though no chest pain nor difficulty of breathing noted. No consult done. No meds taken. Few hrs PTA, there was another episode of passage of tarry stools, 200mL. no chest pain, difficulty of breathing, loss of consciousness, no seizure noted. Persistence of symptoms prompted consult and subsequently the admission. Past Medical History (+) DM maintenance on Gliclazide and metformin. (+) HPN maintenance on metoprolol s/p cholcystectomy 1998 Family History Patient denies heredofamilial disease. Personal and Social History Nonsmoker and nonalcoholic beverage drinker Review of Systems General: no weight loss, no anorexia HEENT: no blurring of vision, no tinnitus, no headache Respiratory: no cough, no hemoptysis, no difficulty of breathing Cardio: no palpitations, (-) orthopnea (-) PND GIT: No constipation GUT: no nocturia,(-) dysuria, (-) hematuria, no frequency Hematologic: no easy brusability Neurologic: no seizure Physical Examination: Patient is awake, not in cardiorespiratory distress Vital Signs: BP: 130/90 HR: 68 RR:18 Temp: 36.8oC HEENT: pale palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, no NVE CHEST AND LUNGS: symmetrical chest expansion, no retraction, clear breath sounds HEART: adynamic precordium, NRRR, no murmur ABDOMEN: ascitic, NABS, soft, non-tender EXTREMITIES: (+) gr.III bipedal edema; no cyanosis with full equal pulse. (-) edema DRE: good sphincteric tone, no skin tags, no ass palpable, (+) melena upon removal of examining finger. Assessment: UGIB prob 2 to PUD HCVD CAD NSR II-B DM type 2 s/p EGD Course in the Ward: Upon admission, Patient was placed on NPO temporarily. She was hooked to IVF: PNSS 1L x 8 hours. Diagnostics requested were 12 lead ECG, CBC c PC, urinalysis, CXR- PA, FBS, BUN, Crea, Na, K, EGD, Blood typing. Therapeutics given were: 1. Omeprazole 40mg /amp TIV q12 2. Sucralfate 1g/tab TID PO 3. Reg. Insulin 5u SQ for CBG ≥250mg/dL

4. 5.

Furosemide 40mg/amp TIV OD with BP precautions Secure and Transfuse 2 unit PRBC properly typed and crossmatched.

On the 2nd HD, vital signs were stable. patient was maintained on NPO and IVF. Additional labs requested were TPAG, Hepatitis profile, protime, TB, B1, B2, SGPT, SGOT and whole abdomen UTZ (Results are shown below). Therapeutics given was continued. And she was started to H. pylori eradication treatment. On the 3rd – 8th HD, vital signs were as follows: BP110-150/70-90 afebrile with normal respiratory and cardiac rate. She still have (+) melena and pallor but was not associated by abdominal pain although eventually the melena resolved. Serum Albumin showed decreased level, thus Aminoleban sachet in a glass of H2O was given and 3 eggwhites was included in the diet, Imidapril 10 mg, Simvastatin 20mg, Intermediate Insulin also given at 10 u am and 5 u pm. Paracentesis was done draining of about 2 L then another 2.1L which was straw colored. 24 hour urine protein, cell count diff count of peritoneal fluid done as well as serum potassium. On the 5th hospital day, patient was asymptomatic with VS: ------ patient was discharged with the ff home meds: 1. Imidapril 10 mg/tab, 1 tab OD 2. Spironolactone 25 mg/tab, 1 tab BID 3. Furosemide 40 mg/tab, 1 tab BID x 5 days 4. Omeprazole 40 mg/tab, 1 tab BID x 7 days 5. metronidazole 500mg/tab, 1 tab BID x 6 days 6. Clarithromycin 500mg/tab 1 tab BID x 6 days 7. Simvastatin 10mg/tab, 1 tab OD at HS 8. Intermediate Insulin 8 u/ SQ at am and 4 u/SQ at pm SGPT and SGOT still requested on OPD basis. Laboratory Results: X-RAY 080807 Patchy infiltrates are seen in the right lower lobe with blunting of the CP sulcus, consider pneumonia with pleural effusion. Heart is magnified. AA (08/21/07) CXR- atheromatous aorta ECG (08/21/07) Within normal limits EGD 080907 Duodenal bulb Ulcer. Abdominal CT scan 0810 Impression: Thickened walls with reflux of contrast and aerobilla in the common bile duct and intrahepatic ducts. Consider post-inflammatry changes/ulcer formation versus malignancy. Suggest gastroscopy with biopsy. Moderate Ascites s/p cholecystectomy Multiple bilateral renal Calyceal stones Minimal bilateral pleural effusion Complete Blood Count Normal Values WBC 4.8-10.8 x 109 /L RBC 4.0-6.20 x 1012 /L Hgb 12-16g/dl Hct 37-47 % MCV 80-90 fL MCH 27-31 MCHC 32-36 Platelet 150-400 x 10^9/L Neutrophils 55-57 Lymphocytes 20-30% Monocytes 0-7% Eosinophils 0-3% Basophils 0-1% Protime 15 secs Activity 73.2% INR 1.2 aPTT36.8 Hepatitis Profile HBsAg – nonreactive 0.454 Anti-HBs Reactive 50.72 Anti-HBc Reactive 0.916 HBeAg Nonreactive 0.089 Anti HBe non reactive1.42 Anti HAV IgM 0.335 Nonreactive Blood Chemistry Result BUN Creatinine 24.7 151

Aug 21 9.3 2.4 7.5 21.7 92.2 31.8 35 173 64.2 20.2 12 3.5 0.1

Aug 22 11.9 3.1 9.8 28.5 92 31.5 34 170 80.8 9.6 6.6 2.2 0.8

Aug 23 6.8 3 9.4 28 93.7 31.5 33.6 174 70.6 18.6 5.5 5.1 0.2

Aug 24 6.9 3 9.7 28.1 93 32.2 35 176 73.8 19.2 2.6 4.3 0.1

Aug 24 6.8 3 9.9 28.1 92.4 32.6 35 184 73.5 18.4 3.3 4.3 0.5

AST ALT Total Protein Albumin S. Globulin Sodium Potassium TB B1 B2 HDL LDL Cholesterol Trigyceride Alk PO4

50 37 57.7 - - 50 16 - - 17 – 18 41.7 -- 33 135 4.4 23.6 8.4 15.2 1.03 1.52 3.34 1.74 100.8 (0816)

Ultrasound (Aug 24) Liver PArenchymal Disease Nephrolithiases, Left Renal PArenchymal Disease, Bilateral Massive Ascites Normal Spleen Bacteriology 081607 Peritoneal Fluid – no growth after 48 hrs of incubation PMN <10/LPF NO AFB seen Cell count diff count 081607 Dark yellow, clear fluid with coagulum amt of 2000cc Total cell count 15x 10 (6)/l Leukocyte count 15x10(6)/l RBC count 0 Lymphocyte 90% Segmenters 10%


				
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