XAVIER UNIVERSITY – ATENEO DE CAGAYAN

DR. JOSE P. RIZAL SCHOOL OF MEDICINE

DEPARTMENT OF INTERNAL MEDICINE

PRECEPTOR: Jovy Bacot, MD, FPCP

STUDENT: Lady Jean U. Cantero
CLINICAL ROTATION: INTERNAL MEDICINE – NMMC 3rd FLOOR WARD
DATE & TIME OF INTERVIEW: January 7, 2020; 8:00am

CASE PROTOCOL
SUBJECTIVE:
General Data:
A case of patient L.A, 61 years old, male, Roman Catholic by religion, residing at
Gingoog City, Misamis Oriental.
The informants are the patient and his son, with a combined reliability percentage of 90.

Chief Complaint: Abdominal Pain

HPI:
1 year prior to admission, patient noted onset of intermittent burning epigastric pain, with
pain scale of 7/10, radiating to left subcostal region. Pain was relieved temporarily with intake of
Mefenamic acid 500 mg/tab, 1 tablet as needed for pain. Pain is triggered by both fast and full
state and is not associated with vomiting, fever, loose stools, or weight loss. Patient also
palpated a marble-sized, non-movable mass on left subcostal region and was painful. Patient
tolerated his condition hence no medications nor was consultation sought.
1 month prior to admission, patient noted an increase in the size of the mass, from
marble-sized to palm-sized, still associated with intermittent burning epigastric pain (7/10) and
triggered by both fast and full state. Patient also noted having loose clothings hence estimated a
10% weight loss. Still, no consultation was done.
2 weeks prior to admission, patient documented increased severity of abdominal pain,
from pain scale of 7/10 to 9/10, still intermittent and burning in characteristic, and now
associated with tarry stools of unrecalled volume, occurring twice a day. Still no consultation
was done.
1 day prior to admission, persistence of abdominal pain and tarry stools documented.
This is now associated with one episode of low grade fever, no medications were taken. Patient
tolerated condition, no consultation was done.
Few hours prior to admission, patient noted persistent and increasing scale of 10/10
burning epigastric pain, and also documented a gnawing pain (10/10) on the left subcostal
region, associated with retching. Symptoms persisted, hence, prompted admission.

Past Medical History

On the year 2012, patient had a stab wound on left back area. Patient was diagnosed
with PTB 20 years ago however no medications were taken.

Personal and Social History:

Patient was a farmer. He started smoking at the age of 15 and stopped by the age of 30,
with 23 pack years, persistent productive cough prompted patient to stop. He was also an
occasional alcoholic drinker and denied use of any illegal drugs.
Family History:
No history of heredo-familial diseases.
Review of Systems:
General Skin HEENT
(-) Unusual weight changes (-) Dryness (+) headache
(-) Unusual weakness (-) Lumps (-) dizziness
(-) Changes in appetite (-) Sores (-) excessive tearing
(-) Easy fatigability (-) Pruritus (-) nasal stuffiness
(-) rhinitis
(-) sinusitis
(-) bleeding gums
(-) sore throat
(-) swollen lymph nodes
Breasts Respiratory Cardiovascular
(-) Pain (+) Productive cough (-) Orthopnea
(-) Nipple discharges (+) SOB (-) Cyanosis
(-) Lumps (-) Chest pain/discomfort (-) Palpitations
(-) Dimpling (-) Hemoptysis
Peripheral vascular Gastrointestinal Genitourinary
(-) Color changes (+) Nausea or vomiting (-) incontinence
(-) Hematoma (-) Pain in defecation (-) frequency
(-) Edema (-) Diarrhea (-) pain on urination
(-) Constipation
(+) Melena
Musculoskeletal Psychiatric Endocrine
(+) Muscle or joint pain (-) Nervousness (-) Heat intolerance
(-) Limitation of movement (-) Tension (-) Excessive thirst
(-) Limping (-) Depression (-) Excessive sweating
(-) Stiffness (+) Night sweats
Neurologic
(-) Fainting
(-) Pins and needles
(-) Seizures

OBJECTIVE:

Physical Examination:

General Survey: Patient was examined awake, coherent, oriented, and not in respiratory
distress
General Appearance: Cachectic
Vital Signs:
BP: 90/60 mmHg HR: 125 bpm
RR: 32 cpm Temperature: 36.9 ºC
O2 sat: 90%
Anthropometrics:
Height: 159cm Weight: 40kg BMI: 15.82kg/m2

Skin: Pale, no jaundice, warm to touch, and dry. No lesions and bruises.
HEENT: Anicteric sclera, pale palpebral conjunctiva.
Cardiovascular: Adynamic precordium, distinct heart sounds, tachycardic, no murmurs.
Chest and Lungs: Equal chest expansion, (+) wheeze
Abdomen: Flat abdomen, (+) palpable mass on epigastrium, (+) decreased bowel sound
Genitourinary: (-) Kidney punch sign
Extremities: (-) Bipedal edema
Neurologic: Reflexes & Muscle Strength:
CN I: Intact
CN II, III: Full extraocular movement
CN VIII: Intact
CN IX, X: (-) Gag reflex
CN XI: Good shoulder resistance
CN XII: (+) Tongue at midline

Laboratory Evaluation:
US: Splenomegaly
Presence of huge solid mass gastric area, suggest follow – up study with CT – Scan

PROBLEM LIST:

PROBLEM DATE ONSET ACTIVE DATE INACTIVE/RESOLVED

PROBLEM RESOLVED PROBLEMS
1 November Abdominal pain,
2018 Gastric mass,
Anemia
2 November Splenomegaly
2018
3 December Productive
2019 Cough

INITIAL PLAN:

Problem 1: Abdominal pain, Gastric Mass, Anemia

Assessment: PUD, Gastric Malignancy vs. Extrapulmonary TB
Peptic Ulcer Disease (PUD) is considered because the patient manifested with
epigastric tenderness which is the most frequent finding in patients’ with GU or DU. With
regards to the age, PUD more often occurs in individuals >60 years old and patient L.A is 61
years old. In this case, tachycardia is common and may suggest dehydration secondary to
vomiting or active GI blood loss. Patient also presented with melena which suggests upper GI
bleeding and GI bleeding is the most common complication that is observed in PUD. (Harrison’s
20th ed.)
Another differential diagnosis is Gastric Malignancy, wherein it is considered because of
the patient’s age which is old, a male gender, history of smoking and probable history of chronic
PUD caused by H. pylori. Patient also had stomach discomfort/pain, melena, and weight loss for
no known reason. (www.cancer.gov/types/stomach/patient/stomach-treatment-pdq)
Lastly, Extrapulmonary TB in the GI is uncommon and occurring in any portion of the GI
tract. Abdominal pain (at times similar to that associated with appendicitis) and swelling,
obstruction, hematochezia, and a palpable mass in the abdomen are common findings at
presentation. Fever, weight loss, anorexia, and night sweats are also common. (Harrison’s 20th
ed.)
Dx: CBC, Platelet, Blood typing, Prothrombin time, aPTT, Crea, BUN, Serum
Electrolytes, CBG, ECG, Stool antigen test for presence of H. pylori, EGD, Schedule for
Plain Abdominal CT Scan and Biopsy
Tx: Admit
IVF: D5NM 1L at 30 gtt/min
Tramadol 50 mg IV now
Omeprazole 40 mg IV q12
Octreotide 250 mg + D5W 250 cc @ 30cc/h
Request 5 units Whole Blood for transfusion
 Refer to Gastro for further evaluation and co-management
Patient Education: Note bleeding signs (gum bleeds, hemoptysis, hematemesis,
hematochezia, and melena)
Avoid strenuous activities
Avoid irritant and dark colored foods

Problem 2: Splenomegaly
Assessment: Splenic Metastasis 2º Gastric Adenocarcima vs. Primary Gastric
Lymphoma
Splenic Metastasis from Gastric Adenocarcinoma is considered however it is very rare
and generally detected as part of multiorgan carcinoma. One of the primary sources of splenic
metastases is Gastric Carcinomas and it accounts for 6.9%. Patients complain of fatigue weight
loss, fever, abdominal pain and splenomegaly, anemia, or thrombocytopenia. The said
complains was present to patient L.A.
(www.ncbi.nlm.nih.gov/pmc/articles/PMC3746397/#__ffn_sectitle)
Primary Gastric Lymphoma is considered however it is relatively uncommon, and is
accounting for <15% of gastric malignancies. Stomach is the most frequent extranodal site for
lymphoma. It is difficult to distinguish clinically from Gastric Adenocarcinoma becuase both
tumors are most often detected during the sixth decade of life. It presents with epigastric pain,
early satiety, and generalized fatigue and is usually characterized by ulcerations with a ragged,
thickened mucosal pattern demonstrated by contrast radiographs or endoscopic appearance.
cytologic brushings of the gastric mucosa but usually requires a biopsy at gastroscopy or
laparotomy might help in distinguishing. (Harrison’s 20th ed.)
Dx: CBC, EGD, Blood smear, Reticulocyte count, Bone marrow examination
Tx: Splenectomy
Patient Education: Wear face mask to avoid nosocomial infection exposure
Avoid placing excessive force on left upper quadrant to prevent
splenic rupture

Problem 3: Productive Cough

Assessment: CAP – MR vs. PTB vs. COPD
Community acquired pneumonia is considered due to the risks factors linked to the
patient such as being a 23 pack years smoker, old age, and absence of gag reflex upon
physical examination. Patient had episodes of low grade fever and night sweats. He is
tachycardic (125bpm), tachypneic (32cpm), and noted with wheezing on all lung fields. Having
comorbidities such as gastric masses is considered as having moderate risk. (CPG 2010
Update)
Another differential diagnosis is Pulmonary Tuberculosis (PTB), it is considered due to
its prevalence and also as per patient’s history wherein he was diagnosed 20 years ago. He did
not take any drug regimen since diagnosed. Low grade fever and night sweats were also
present. (Harrison’s 20th ed.)
Lastly, Chronic Obstructive Pulmonary Disease is considered because patient was a 23
pack years smoker hence he is at risk of developing COPD. Cough, sputum production and
exertional dyspnea are the most common presentation of COPD patients in the early stages and
the patient manifested two out of three. (Harrison’s 20th ed)
Dx: Chest X-ray PAL, AFB, GS/CS, Spirometry, ABG
Tx: N-acetylcysteine 600 mg/tab 1 tab + 75 cc H20 OD HS
Salbutamol 1 nebule q12h
Oxygen 2L/min via nasal cannula
Patient Education: Wear mask to prevent spread
Promote head of the bed elevation
Promote proper sputum disposal
Advice to increase fluid intake
PROGRESS NOTES:

Problem 1: Abdominal pain, Gastric Mass, Anemia

Day 1 (January 7, 2020)

SUBJECTIVE Epigastric Pain (9/10), Tarry stools
OBJECTIVE Patient is conscious, coherent and cooperative.
Vital signs:
BP= 90/60 mmHg (supine and sitting)
HR= 110bpm
Skin is pale, pale palpebral conjunctiva, anicteric sclera
Distended neck veins, JVP=8cm
Abdominal exam: (+) epigastric tenderness, (+) palpable spleen
CRT >3sec
CBC: Hgb = 3 Hct = 11 WBC = 12,100
CBG: 137mg/dL
Blood type: B+
BUN: 19.83
Crea: 0.86
Na: 141.5 meq/L
K+: 4.23 meq/L
ASSESSMENT Pain is relieved when given with medications. Tarry stools still noted.
PLAN
Dx. Follow-up Prothrombin time, aPTT, Stool antigen test for presence of H.
pylori, EGD, Plain Abdominal CT Scan and Biopsy
Tx. Continue medications
IVF TF: D5NM 1L @ 30gtt/min
Follow-up request for blood transfusion, once secured request for cross
matching
Follow-up referral request to Gastro for evaluation and co-management
Patient Education: Note bleeding signs (gum bleeds, hemoptysis, hematemesis,
hematochezia, and melena)
Avoid strenuous activities
Avoid irritant and dark colored foods
Day 2 (January 8, 2020)
SUBJECTIVE Burning epigastric pain (7/10), Fatigue
OBJECTIVE Patient is awake, alert, and responsive
Vital signs:
BP=100/60mmHg
HR = 115bpm
Pale skin, palms and soles, pale palpebral conjunctiva
(+) epigastric tenderness, (+) palpable spleen
CRT >3sec
ASSESSMENT Pain is manageable with the aid of medications, no tarry stools
PLAN
Dx. Follow-up laboratory and imaging requests
Tx. Continue medications
IVF TF: D5NM 1L @ 30gtt/min
Follow-up request for blood transfusion, once secured request for cross
matching
Follow-up referral request to Gastro for evaluation and co-management
Patient Education: Note bleeding signs (gum bleeds, hemoptysis, hematemesis,
hematochezia, and melena)
 Avoid strenuous activities
Avoid irritant and dark colored foods
Day 3 (January 9, 2020)
SUBJECTIVE Burning epigastric pain (5/10), Tarry stools, Fatigue
OBJECTIVE Patient is awake, alert, and cooperative
Vital Signs:
BP=100/60mmHg
HR=125bpm
Pale skin, palms and soles, pale palpebral conjunctiva
(+) epigastric tenderness, (+) palpable spleen
CRT >2sec
ASSESSMENT Pain is improving, still with fatigue and tarry stools recur
PLAN
Dx. Follow-up laboratory and imaging requests
Repeat CBC, Crea, Na, K+
Tx. Continue medications
IVF TF: D5NM 1L @ 30gtt/min
Follow-up request for blood transfusion, once secured request for cross
matching
Follow-up referral request to Gastro for evaluation and co-management
Patient Education: Note bleeding signs (gum bleeds, hemoptysis, hematemesis,
hematochezia, and melena)
Avoid strenuous activities
Avoid irritant and dark colored foods
Day 4 (January 10, 2020)
SUBJECTIVE Burning epigastric pain (4/10), Tarry stools, Fatigue
OBJECTIVE Patient is conscious, coherent and cooperative
Vital Signs:
BP=90/60mmHg
HR=138bpm
Pale skin, palms and soles, pale palpebral conjunctiva
(+) epigastric tenderness, (+) palpable spleen
CRT >2sec
CBC: Hgb = 2.9 Hct = 10.30 Plt = 217,000
Crea: 0.81
K+: 3.72
Na: 133.8
ASSESSMENT Pain is improving, still with tarry stools and fatigue
PLAN
Dx. Follow-up laboratory and imaging requests
Tx. Continue medications
IVF TF: D5NM 1L @ 30gtt/min
Follow-up request for blood transfusion, once secured request for cross
matching
Follow-up referral request to Gastro for evaluation and co-management
Patient Education: Note bleeding signs (gum bleeds, hemoptysis, hematemesis,
hematochezia, and melena)
Avoid strenuous activities
Avoid irritant and dark colored foods

Problem 2: Splenomegaly

Day 1 (January 7, 2020)

SUBJECTIVE Gnawing pain on left subcostal region
OBJECTIVE Patient is conscious, coherent and cooperative.
(+) Splenomegaly
CBC: Basophil=5.9
US: Spleen is enlarged measuring 106 x 64mm, homogenous
ASSESSMENT Pain is relieved when given with medications
PLAN
Dx. Follow-up EGD, Blood smear, Reticulocyte count, Bone marrow
examination
Tx. IVF TF: D5NM 1L @ 30gtt/min
Patient Education: Wear face mask to avoid nosocomial infection exposure
Avoid placing excessive force on left upper quadrant to prevent splenic
rupture
Day 2 (January 8, 2020)
SUBJECTIVE Gnawing pain on left subcostal region
OBJECTIVE Patient is conscious, coherent and cooperative.
(+) Splenomegaly
ASSESSMENT Pain is manageable with aid of medications
PLAN
Dx. Follow-up laboratory and imaging requests
Tx. IVF TF: D5NM 1L @ 30gtt/min
Patient Education: Wear face mask to avoid nosocomial infection exposure
Avoid placing excessive force on left upper quadrant to prevent splenic
rupture
Day 3 (January 9, 2020)
SUBJECTIVE Gnawing pain on left subcostal region
OBJECTIVE Patient is conscious, coherent and cooperative.
(+) Splenomegaly
ASSESSMENT Pain is improving
PLAN
Dx. Follow-up laboratory and imaging requests
Tx. IVF TF: D5NM 1L @ 30gtt/min
Patient Education: Wear face mask to avoid nosocomial infection exposure
Avoid placing excessive force on left upper quadrant to prevent splenic
rupture
Day 4 (January 10, 2020)
SUBJECTIVE Gnawing pain on left subcostal region
OBJECTIVE Patient is conscious, coherent and cooperative.
(+) Splenomegaly
CBC: Basophil=6.20
ASSESSMENT Pain is improving with medications
PLAN
Dx. Follow-up laboratory and imaging requests
Tx. IVF TF: D5NM 1L @ 30gtt/min
Patient Education: Wear face mask to avoid nosocomial infection exposure
Avoid placing excessive force on left upper quadrant to prevent splenic
rupture

Problem 3: Productive Cough

Day 1 (January 7, 2020)

SUBJECTIVE Productive cough, SOB
OBJECTIVE Patient is conscious, coherent and cooperative.
Vital Signs:
 RR=24cpm
O2 Sat: 99% with O2 support via Nasal Cannula
Bibasal wheezing and rales
Labs:
WBC = 12,100; Baso = 5.9; Eosi = 6.1;
Lympho = 8; Neutro = 88
CXR: Old Granulomatous Infection (PTB)
ASSESSMENT Productive cough still present
PLAN
Dx. Follow-up AFB, GS/CS, Spirometry, ABG
Tx. N-acetylcysteine 600 mg/tab, 1 tablet + 75 cc H20 OD HS
Salbutamol 1 nebule q12h
Oxygen 2L/min via nasal cannula
Patient Education: Wear mask to prevent spread
Promote head of the bed elevation
Promote proper sputum disposal
Advice to increase fluid intake
Day 2 (January 8, 2020)
SUBJECTIVE Productive cough, SOB, Fever
OBJECTIVE Patient is conscious, coherent and cooperative.
Vital Signs:
Temp=38..2ºC
RR=25cpm
O2 Sat: 99% with O2 support via Nasal Cannula
Bibasal wheezing and rales
ASSESSMENT Cough still present and is associated with fever
PLAN
Dx. Follow-up laboratory requests
Tx. Continue medications
Paracetamol 500mg 1 tab q6hr as needed for T= >37.5 ºC
Patient Education: Wear mask to prevent spread
Promote head of the bed elevation
Promote proper sputum disposal
Advice to increase fluid intake
Advice tepid spongebath and change of light sheeted clothes
Day 3 (January 9, 2020)
SUBJECTIVE Productive cough, SOB, Fever
OBJECTIVE Patient is conscious, coherent and cooperative.
Vital Signs:
T = 37.6 ºC
RR =30 cpm
O2 Sat = 99% with O2 via nasal cannula
(+) Bibasal wheezing and rales
ASSESSMENT Still with cough and fever
PLAN
Dx. Follow-up laboratory and imaging requests
Tx. Continue medications
Patient Education: Wear mask to prevent spread
Promote head of the bed elevation
Promote proper sputum disposal
Advice to increase fluid intake
Advice tepid spongebath and change of light sheeted clothes
Day 4 (January 10, 2020)
SUBJECTIVE Productive cough with yellowish sputum
OBJECTIVE Patient is conscious, coherent and cooperative.
 Vital Signs:
T = 37.6 ºC
RR = 28cpm
O2 Sat =98% with O2 support via Nasal Cannula
(+) Wheezing all over lung fields
CBC:
WBC = 8,700; Basophil: 6.2%; Eosinophil: 1.40
Lympho: 11 .30; Neutro: 81.10
ASSESSMENT Cough is improving and fever still present
PLAN
Dx. Follow-up laboratory requests
Tx. Continue medications
Patient Education: Wear mask to prevent spread
Promote head of the bed elevation
Promote proper sputum disposal
Advice to increase fluid intake
Advice tepid spongebath and change of light sheeted clothes