Case #2

A 58-year-old woman was referred to a hospital from primary care provider

due to consistent discomfort and significant weight loss. She looked for a PCP’s
advice as she had a tarry stool in the early morning which she had never experienced
before. She presented with a 2-month history of burning pain in the epigastric
abdomen and chest which radiated toward her back. Her pain worsened after drinking
coffee, and was relieved after taking antacids. She had previously lost 10 pounds in 2
months due to decreased intake caused by the feeling of bloating, early fullness and
stomachaches between meals. She also reported nausea and vomiting. She expressed
concern especially because the food appeared undigested when she vomited. She also
reported doubling her NSAID intake due to increased knee pain. She looked pale and
exhausted when she entered the clinic.
Upon physical examination, there is a significant pain in the epigastric region.

Medical history
1. Diabetes Mellitus and hypertension diagnosed 6 years ago.
2. No surgical history.

family history
1.Mother died from gastric cancer 10 years ago.
2.One son alive and well at age 29.
3.One daughter at age 35, alive and has recurrent Gastritis.
Pertinent social history
1.Has worked full-time as a nurse during 30 years.
2.Divorced with her husband 20 years prior, raised 2 children by herself.
3.Hobbies include drinking, eating spicy food, watching dramas and talkshow.
4.No smoking

Vital Signs and Measurements

1.BP: 134/79 mm Hg
2.HR: 76 bpm
3.RR: 15 b / min
4.Temperature: 36.1 ℃
5.Pulse oxygenation: 99%
6.Height: 167 cm
7.Weight: 58.2 kg

Gastroscopy Report:
Oesophagus oesopahageal junction were normal. Cardia is normal. In pyloric
part there is a ulcer size 1.2 +1.5 cm. with a punched-out ulcer base and whitish
fibrinoid exudates. Duodenum is normal.

Laboratory results:

WBC 5.9 x 10ˆ9/l(4.00 – 10.00)

(12.1 – 15.1
Hb 11.0g/dl
g/dl)
248 x
Platelets (150 – 400)
10ˆ9/l
CRP 3.4 mg/l (0 – 5 mg/l)

Urea and
Electrolytes:
(135 – 147
Na 137 mmol/l
mmol/l)
(3.3 – 5.0
K 3.5 mmol/l
mmol/l)
(99 – 113
Cl 96 mmol/l
mmol/l)
(2.5 – 7.0
Urea 3.3 mmol/l
mmol/l)
(60 – 12
Creat 32 umol/l
umol/l)
WBC 5.9 x 10ˆ9/l(4.00 – 10.00)
Urea breaht test:Positive Negative

Liver Function
Test:
(3 – 18
Total Bili 7 umol/l
umol/l)
Conjugated Bili 3 umol/l (0 – 5 umol/l)
Total Protein 74g/l (60 – 80 g/l)
ALP 66 U/l (30 – 120 U/l)
GGT 7 U/l (5 – 35 U/l)
AST 41U/l (5 – 45 U/l)
ALT 25U/l (5 – 45 U/l)
Thyroid
Function Test:
(10.3 – 21
Free T4 19.7pmol/l
pmol/l)
(0.35 – 4.50
TSH 1.8 mIU/l
mIU/l)

(2.12 – 2.65
Calcium 2.13mmol/l
mmol/l)
Albumin 27 g/l
(0.8 – 1.4
Phosphate 0.9 mmol/l
mmol/l)
Ig G and M to H.
29,1 Negative
pylori
HIV Negative

Urine MCS:
Leucocytes Trace
Bacteria Absent

Stool MCS:
WBC 5.9 x 10ˆ9/l(4.00 – 10.00)
Brown Unformed

Erythrocytes Negative
Not
Parasites
observed
Aerobic Not
organisms isolated
Calprotectin 31 0-50
C difficile toxin
Negative
A
C difficile toxin Negative

Chest X-ray: