#1 ABRIO, Kyra Cheyenne Nicholle D.

1NUR8
SUMMATIVE EVALUATION OF CASE ANALYSIS

1. This is an individual activity

2. Each student must answer the following cases.
3. Students should be guided according to the normal and abnormal findings as stated in the case.
4. Prior readings are necessary.
5. For discussion and clarification, students may communicate to their respective HA Lecturers
depending on the availability of both students and Professors.
6. Take note of schedule deadline of submission (Be guided by our TLA)

GI-GU Cases

Patient is Rodrigo, 52 y/o male who was brought to the emergency room early 4 am today. According to his
wife, he suddenly vomited fresh blood prior to consultation and has been complaining of severe epigastric
pain with a pain scale ranging from 5-9/10 which started 2 days ago. They were not able to bring the patient
to the nearest hospital because of the community quarantine. Patient claims that the epigastric pain was
intermittently felt before because of his Peptic Ulcer Disease diagnosed 5 years ago and he was
maintained on Omeprazole 40 mg/tab 1 tab 2x a day. He is also hypertensive for 10 years maintained on
Losartan 50 mg, 1 tab 2x a day and Diltiazem 60mg per tab 1 tab once a day. He works in an advertising
agency as an editor and usually skip meals and drink coffee to keep him awake. Last January 10, 2020, he
underwent annual Physical examination. Significant findings then were as follow:
BP 150/90, HR 90/min, RR 16/min, T 36.8. No signs of respiratory distress
Head and Neck findings: normal
Chest and Neck: Apex beat on the 6th intercostal space anterior axillary line, diffused and sustain; S1>S2 at
the apex, S2>S1 in the base, no significant murmur appreciated. Clear breath sound.
Abdomen: Flat, no scarring, normoactive bowel sound, no direct and rebound tenderness on all quadrants,
(+) 6x 8 cm non-pulsating mass noted at the epigastric area which is non tender as well. Tymphanitic at all
quadrant except for the liver dullness and mass located at the epigastric area.
Ultrasound of the whole abdomen showed a solid mass located at the epigastric area consisted with a
gastric tumor, however a more reliable imaging such as Triple Contrast CT Scan was recommended to
verify the findings. 2 months prior to consultation, Rodrigo felt early satiety and bloatedness. He also
claimed to have loss of appetite and noticed progressive weight lost. He denies any chest pain, dyspnea,
headache, blurring of vision, palpitation, heat and cold intolerance. His wife verbalized that 1 week prior to
consultation, she noted his husband to have episodes of vomiting of previously ingested food and easy
fatigability.
At the ER, you are the nurse assigned to him. Patient is restless, shouting in pain. Initial VS: 80/50, HR
130/min, RR 22/min, Temp 38.5 C. Clear breath sound, tense abdomen, (+) violaceous to bluish
discoloration on the peri-umbilical and flank area, with hyperactive bowel sound, (+) direct and rebound
tenderness on all quadrants, patient refused further exam related to the abdomen.
He was referred to surgery and the initial impression was a Perforated Peptic Ulcer VS Ruptured Gastric
Tumor with signs of Spontaneous abdominal Peritonitis. He was immediately scheduled for CT Scan and
Emergency Exploratory Laparotomy.

For guided analysis of case:

1. Review anatomy and physiology of GI particularly the Stomach and Peritoneum
2. Review components of History taking and PE of abdomen
3. Read on signs and symptoms related to Peptic Ulcer Disease and its complications: GI
bleeding, perforation and gastric outlet obstruction as well as Gastric tumor and Peritonitis.
(Kindly guide students in classifying the manifestations according to IAPP examining tool)

Guide questions:
1. Kindly accomplish the following based from the case given:

Parts of History ANSWER

Chief Compliant Patient complained of severe epigastric pain that has spanned for two
(1 point) days and that he vomited fresh blood. What really prompted the patient
to be rushed to the ER (hematemesis)
airway, breathing, circulation(3rd priority) – ABC EMERGENCY CASE
#1 ABRIO, Kyra Cheyenne Nicholle D.
1NUR8
History of present  5 years ago, patient would feel intermittent epigastric pain.
illness (based from the  January 10, 2020 – Patient underwent annual Physical
chronological appearance of
manifestation) examination; notable findings: non-tender 6x 8 cm non-
pulsating mass noted at the epigastric area, abdominal
4 points- if all data in the history ultrasound shows a solid mass located at the epigastric area
were correctly and completely
stated
consisted with a gastric tumor.
3 points- if 2 important details
were missed
2 points- if 3 important details  2 months prior to consultation, the patient experienced early
were missed satiety and bloatedness. Claimed to have a loss of appetite and
1 point- if >3 important details
were missed or the progressive weight lost.
chronological order were not
followed
 1 week prior to consultation the patient had episodes of
vomiting of previously ingested food and experienced easy
MAKE IT SPECIFIC AND
SHORTER (+), (-), quantity, fatigability according to his wife.
description

 2 days prior to consultation the patient started experiencing

severe epigastric pain with a pain scale ranging from 5-9/10. –
qualify the pain

 A few hours Prior to consultation, patient vomited blood.

 Currently, the patient exhibits restless and is shouting in pain.

His abdomen is tense and there is a violaceous to bluish
discoloration on the peri-umbilical and flank area. He also had
hyperactive bowel sound and direct and rebound tenderness on
all quadrants.
Review of System General
 Progressive weight loss
(1 point if all were stated
correctly; 0.5 point if some part
 Easy easy fatigability
of ROS were missed )  Temperature of 38.5 (at the ER)
HEENT
STARTS WITH  Normal findings
RESPI OR CARDIO  No headache
 No blurring of vision
cepalo-caudial Respiratory
 No dyspnea
 RR = 22/min - Tachypneic (at the ER)
Cardiovascular
 Hypertensive for 10 years
 No chest pain
 No palpations
 VS: 80/50 - Severe Hypotensive, HR 130/min – Tachycardiac
(at the ER)
Psychiatric
 Patient is restless and shouting in pain
Skin & Integumentary
 Violaceous to bluish discoloration on the peri-umbilical and flank
area (at the ER)
Endocrine
 No heat and cold intolerance
Gastrointestinal 
 Vomiting of food as well as blood
 Presence of severe epigastric pain
 Early satiety and bloatedness
 Loss of appetite
 Tense abdomen (at the ER)
 Hyperactive bowel sound (at the ER)
  Presence of direct and rebound tenderness on all quadrants (at
the ER)
Previous Medical The patient has been hypertensive for 10 years and maintains it with
History (include Losartan 50mg, 1 tab taken twice a day and Diltiazem 60mg/tab once a
maintenance medications) day. He was also diagnosed with Peptic Ulcer disease 5 years ago due
#1 ABRIO, Kyra Cheyenne Nicholle D.
1NUR8

(1 point if all were correctly

to intermittent epigastric pain and using Omeprazole 40mg/tab taken
stated; 0.5 point if some details twice a day as maintenance. He had an annual physical examination on
were missed) the 10th of January 2020, significant findings include a non-tender 6x8
- Presence of side cm non-pulsating mass noted at the epigastric area. An ultrasound of
-
effects
If magiging effective
the whole abdomen showed a solid mass located at the epigastric area
- Pharmokinetics consisted with a gastric tumor, however he was advised to undergo a
- Intereactions that
may effect the
more reliable imaging such as Triple Contrast CT Scan to verify the
viability of the drug findings.
itself

Risk factors in the Patient’s gender, age, stress from work as well as his habit of skipping
development of meals and frequent consumption of coffee can be considered risk
Peptic Ulcer and factors. Also, the inability to be brought to the hospital immediately due
gastric Tumor based to the community quarantine could have played a part.
from the case
Gastro-irritating ang coffee, causes hyperactivity
(2 points if all were correctly
stated; 1 point if some details
were missed)

2. How will you differentiate an intra-abdominal mass from an abdominal wall mass? (1 point )

During inspection, if possible, ask a patient to contract their abdominal muscles either by raising their head
or feet from the examination table. If the mass is more prominent when muscles are tensed then it is
attached to the abdominal wall and if it isn’t then the mass would be found in the abdomen itself. (better if
stated the other way)

3. Hypothetically: What are the Physical examination findings that you will expect or look for in a
patient with Perforated Peptic Ulcer VS Ruptured Gastric Tumor with signs of Spontaneous
abdominal Peritonitis following the sequence of inspection, auscultation, palpation and percussion.
( include all findings that were already given in the case). Enumerate them accordingly. Indicate all
the signs that were mention in the case (10 points total)

Inspection Auscultation Palpation Percussion

Hematemesis (vomiting Hyperactive bowel (+) Direct and rebound Shifting Dullness due to
of blood) sound tenderness (Blumberg’s Ascites
sign)
Violaceous to bluish Decreased bowel Abdominal guarding Dullness of LUQ due to
discoloration on the sounds (PPU) splenomegaly (gastric
peri-umbilical area cancer)
(Cullen’s sign)
Violaceous to bluish Succussion splash Non-pulsating epigastric (+) percussion
discoloration on flank (Gastric splash) mass tenderness (peritonitis)
area (Turner’s sign)
Abdominal distention Abdominal rigidity Tymphanitic at all
(tense abdomen) quadrant except for the
liver dullness and mass
located at the epigastric
area.
Pallor in the skin(in (+) Fluid wave No liver dullness (in
patients with case of ruptured tumor)
hematemesis and
melena) and lower
conjunctiva
Restlessness + in pain, Pain If may severe pain and
shouting in pain mass, no percussion.
Melena/dark stool Direct tenderness on all Even in bleeding
quadrants tendencies
The mass But cancer bleeding,
severe pain, especially
if defined.
Globular tense
abdomen
#1 ABRIO, Kyra Cheyenne Nicholle D.
1NUR8
The total scores of GI-GU will be 20 points.

Integumentary Case.

A 21 year old female reported to ER with a chief complaint fever and extensive erythematous rashes on the
skin of the face and neck, reddish conjunctiva, ulceration of eyelid and oral cavity and difficulty in routine
oral habits since 3 days ago. According to her, initial lesions are papule like that start in the arms, forearms
and trunk and later on developing to a vesicular lesion. It was also associated with pain which was sudden
in onset, burning type, continuous, localized, and severe in intensity, aggravated on touching, speaking,
eating food & there was no relieving factor. Prior to the complaints, she was prescribed with ciprofloxacin
500 mg per tab 1 tab 2x a day because of difficulty in urination. She has history of recurrent UTI and this
was the first time she was prescribed with Ciprofloxacin. She was taking it for 5 days already before she
developed this type of reaction. The patient was well-oriented but has difficulty in answering questions. On
examination, she has fever of 38.7 C, generalized, maculopapular and bullous eruptions on the neck, face,
external ear. The trunk and lower extremities were having well developed variably sized target like lesions
with scales and plaques. She also complained of burning micturition. Initial impression was Drug induced
skin reaction- To consider Steven Johnson Syndrome

For guided analysis of case:

1. Review anatomy and physiology of the integumentary
2. Review components of History taking and PE of skin which will involve only inspection and
palpation.
3. Read on signs and symptoms related to Drug induced skin lesion and Steven Johnson
Syndrome.

Guide questions:
1. Based from the case given- state important information that must be included in the history of
present illness according to the following:

Components
Onset (1 point)
Changes since onset
5 points- if all data in the onset were correctly
and completely stated
4 points- if 2 important details were missed
3 points- if 3 important details were missed
2 point- if >3 important details were missed
Answers
3 days prior to consultation.
 Initial papule-like (maculo-papula) lesions that
started in the arms, forearms and trunk later
developed to vesicular lesions. These were
associated with severe pain which was aggravated
with pressure and movement.
#1 ABRIO, Kyra Cheyenne Nicholle D.
1NUR8
related to the changes of skin lesion.
 The condition continued to progress to generalized,
maculopapular and bullous eruptions on the neck,
face and external ear. Well-developed variably sized
target like lesions with scales and plaque have also
formed on the trunk and lower extremities.
Possible cause/ An adverse reaction to Ciprofloxacin, which she was taking
Risk factors (1 point) for the first time prior to the appearance of the rashes.

Medical/Family History (1 point) History of Recurrent UTI

Precipitating or worsening Pain is aggravated on touching, speaking and eating food.

factors for the pain or lesion
(2 points if all were correctly stated; 1 point if
some details were missed)
Alleviating factors None.

2. Based from the case given- state important information that must be included in the Physical
examination of the present illness according to the following:

Skin Lesion Type Answers

Primary skin lesion Papula, vesicular lesions, maculopapular eruptions, bullous
(1 point if all were correctly stated; 0.5 point if eruptions and plaques.
some details were missed)

Secondary skin lesion Ulcerations around eyelid and oral cavity.

(1 point if all were correctly stated; 0.5 point if
some details were missed)
Scales. + plaques
Color (1 point) Reddish-brown (erythematous) – define specific color
Shape/Configuration/size Variably sized, “bulls-eye” shaped. ; extensive patch-like
(based on the pictures) (1 point)
Texture (1 point) Rough. Dry + Scaly
Reaction to pressure (1 point) Non-blanching.
Distribution or pattern Generalized lesions on the face, neck, face, external ear as
(1 point if all were correctly stated; 0.5 point if well as trunk and lower extremities.
some details were missed)
Elevation/Depression (1 point) Elevated (papula and bullous eruptions) + depressed sa
ulcer and erosion
Presence of exudates (1 point) None; Serous fluids are present in vesicular and bullous
Other findings  Fever of 38.7 C
(1 point if all were correctly stated; 0.5 point if
some details were missed)  Presence of pain described as burning type,
continuous, localized, and severe in intensity.
 Burning micturition
 Patient was well-oriented but has difficulty in
answering questions

Ulcerations around eyelid and oral cavity.

The total scores of Skin will be 20 points.

Use the Rubric for another 10 points

Summative Evaluation: GI (20 points) + Skin (20 points) + Rubrics (10 points)
#1 ABRIO, Kyra Cheyenne Nicholle D.
1NUR8
References:

Ciprofloxacin Side Effects: Common, Severe, Long Term. (n.d.). Retrieved from
https://www.drugs.com/sfx/ciprofloxacin-side-effects.html
Chung, K. T., & Shelat, V. G. (2017). Perforated peptic ulcer-an update. World journal of
gastrointestinal surgery, 9(1), 1. doi: 10.4240/wjgs.v9.i1.1.
Crosby, K., & Dexter, K. (2018, December 20). Clinical evaluation of peptic ulcer disease –
Page 3 of 5. Retrieved from https://www.clinicaladvisor.com/home/cme-ce-
features/clinical-evaluation-of-peptic-ulcer-disease/3/
Ely, J. W., & Stone, M. S. (2010, March 15). The Generalized Rash: Part I. Differential
Diagnosis. Retrieved from https://www.aafp.org/afp/2010/0315/p726.html
Gogoi, B. (2016). Perforated peptic ulcer: a clinical analysis and outcome. JOURNAL OF
EVOLUTION OF MEDICAL AND DENTAL SCIENCES-JEMDS, 5(22), 1195-1198. doi:
10.14260/jemds/2016/277.
Gossman, W., Tuma, F., Kamel, B. G., & Cassaro, S. (2019). Gastric Perforation. In StatPearls
[Internet]. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov
/books/NBK519554/.
Hogan-Quigley, B., Palm, M. L., & Bickley, L. S. (2017). Bates nursing guide to physical
examination and history taking. 2nd Edition. Philadelphia: Wolters Kluwer .
Lee, S. P., Sung, I. K., Kim, J. H., Lee, S. Y., Park, H. S., & Shim, C. S. (2017). Risk factors for
the presence of symptoms in peptic ulcer disease. Clinical endoscopy, 50(6), 578.
doi: 10.5946/ce.2016.129.
Lin, K. H., Huang, M. L., Chang, N. J., Liou, L. R., Su, M. S., & Tsao, M. J. (2016).
Spontaneous rupture of an extremely large gastrointestinal stromal tumor of the
jejunum. Formosan Journal of Surgery, 49(5), 196-200. doi: 10.1016/j.fjs.2016.05.004
Peptic ulcer physical examination. (n.d.). Retrieved from
https://www.wikidoc.org/index.php/Peptic_ulcer_physical_examination
Shilpashree, H. S., & Sarapur, S. (2012). Ciprofloxacin-induced erythema multiforme. Journal
of
pharmacology & pharmacotherapeutics, 3(4), 339. doi: 10.4103/0976-500X.103696.
Stevens-Johnson syndrome. (2020, April 14). Retrieved from
https://www.mayoclinic.org/diseases-conditions/stevens-johnson-syndrome/symptoms-
causes/syc-20355936
Yusefi, A. R., Lankarani, K. B., Bastani, P., Radinmanesh, M., & Kavosi, Z. (2018). Risk factors
for gastric cancer: a systematic review. Asian Pacific journal of cancer prevention:
APJCP, 19(3), 591. doi: 10.22034/APJCP.2018.19.3.591.