DAVAO MEDICAL SCHOOL FOUNDATION, INC.

– COLLEGE OF MEDICINE
Department of Internal Medicine

Name: MEEVIE LOVE D. TOLEDO

Batch/Sec on: NMD 4 - GROUP 5 Date: NOVEMBER 09, 2021

DAY 2 ACTIVITY

Instruc ons:
● Use Harrison’s Principles of Internal Medicine 20th edi on, Bate’s Guide to Physical Examina on and History Taking, or Clinical Prac ce Guidelines as your reference in answering this case. You may also
use the o cial textbooks used by other departments.
● Indicate the name of the book, chapter and page number in the reference column. Failure to write the reference will incur deduc on from the total grade.
Case:

Height 5’5’’, Weight 65 kgs

Other Physical Examina on Findings

General Survey Vital Signs Skin HEENT Neck

Neck supple
PERRLA, pupil diameter 3mm bilaterally Trachea midline
Awake, coopera ve, coherent T 37.1 C
No lesions Anicteric sclera No palpable nodes
Not in respiratory distress
No nasal drainage No vein disten on
No neck mass

Lungs Heart Abdomen Genitalia/Rectum Extremi es Neuro

Normoac ve bowel sounds
So , nontender, DRE reveals good sphincter tone, no No clubbing, cyanosis CNs II-XII intact
Equal chest expansion PMI at 5th ICS, 7cm from
nondistended masses, no tenderness, empty Pulses 2+ bilateral in all extremi es Muscle strength = 5/5 all extremi es
the midsternal line
No guarding, no rebound rectal vault, and black stool on the Intact ROM Sensory func on = 100% all extremi es
tenderness examining nger
No bruits, no masses

PREPARED BY: M. PLATERO, RN, MD, FPCP 1

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine

PE Findings Describe

Anicteric sclera; Pale conjuc va

Pale nail beds; Koilonychia present; No clubbing

nor cyanosis of ngernails

THEORETICAL MANIFESTATIONS RELATED TO THE PRIMARY IMPRESSION (List all CASE-BASED MANIFESTATIONS (List how the theore cal manifesta ons and risk factors are
REFERENCE
the possible clinical manifesta ons including risk factors of the primary presented by the pa ent. If a manifesta on or risk factor is not present in the pa ent, type ‘not (source, page no.)
impression i.e. predisposing and precipita ng risk factors) men oned’.)
Example # 1: Headache Intermi ent, throbbing, frontal headache, with 5/10 pain scale, nonradia ng ABC XYZ, p. 123
Example # 2: Common among ages 40-60 years old Age of pa ent is 64 years old DEF UVW, p. 456
Example # 3: Common among women Pa ent is a male ABC XYZ, p. 120
Example # 4: Common among Asians Not men oned CBA ABC, p. 321

PREPARED BY: M. PLATERO, RN, MD, FPCP 2

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
H. pylori Not men oned
NSAIDs Pa ent is taking Ponstan (an NSAID) for two years for joint pain
Chronic obstruc ve lung disease Not men oned
Chronic renal insu ciency Not men oned
Current tobacco use Pa ent is non-smoker
Former tobacco use Pa ent is non-smoker
Older age Pa ent is 48 years old
Three or more doctor visits in a year Not men oned
Coronary heart disease Not men oned
Former alcohol use Pa ent is non-alcoholic drinker
Harrison’s Principles of
African-American race Not men oned Internal Medicine 20th
Obesity Pa ent BMI is 23.8 (normal) edi on Chapter 317,
pages 2223, 2226 &
Diabetes Not men oned 2227
Epigastric pain described as a burning or gnawing discomfort Burning epigastric pain
Nausea and/or vomi ng Dizziness and nausea is present along with epigastric pain
Dyspepsia that becomes constant, is no longer relieved by food or antacids, or Epigastric pain radia ng to the right shoulder
radiates to the back may indicate a penetra ng ulcer
Tarry stools or co ee-ground emesis Black stool
Epigastric tenderness Abdominal examina on revealed so , nontender and nondistended abdomen
Tachycardia Not men oned
Orthostasis Not men oned
Severely tender, board-like abdomen Not men oned
Presence of a succussion splash Not men oned

PREPARED BY: M. PLATERO, RN, MD, FPCP 3

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
Ques on/Task Answer Reference
(Source, page no.)

What are the nonmodi able risk factors of Harrison’s Principles of Internal
this pa ent? ● Age Medicine 20th edi on Chapter 317,
page 2223
What are the modi able risk factors of this Harrison’s Principles of Internal
pa ent? ● NSAID use Medicine 20th edi on Chapter 317,
page 2223
Explain the pathogenesis of the black stools of ● NSAID use → COX-1 inhibi on; Toxicity to Gastric epithelial cells → Decreased prostaglandins → ↑ H+ produc on, Harrison’s Principles of Internal
this case ↓ gastric mucous produc on → ↓ Gastroprotec ve factors, ↑ Mucosal injurious substances → Erosion of mucosa Medicine 20th edi on Chapter 44,
→ Erosion proceeds into blood vessels → Bleeding into stomach → Blood passes through tract, becomes oxidized page 273; Chapter 317, pages
by HCl & diges on → Melena 2225-2227
Explain the pathogenesis of dizziness of this Harrison’s Principles of Internal
case Medicine 20th edi on Chapter 93,
page 685
● Pep c ulcer disease → Chronic bleeding → ↑ iron loss → lack of iron the body → not enough iron to synthesize
heme → insu cient hemoglobin → ↓ transport of oxygen to ssues → dizziness The Pa ent History 2nd edi on. An
Evidence-Based Approach to
Di eren al Diagnosis. Chapter 36,
page 367
Explain the pathogenesis of tachycardia of Harrison’s Principles of Internal
● Pep c ulcer disease → Chronic bleeding → ↑ iron loss → lack of iron the body → not enough iron to synthesize
this case Medicine 20th edi on Chapter 93,
heme → insu cient hemoglobin → Tachycardia (to ↑ oxygen delivery to ssues, heart pumps more blood)
page 685
Is doing a DRE signi cant for this case? Jus fy The Washington Manual of Medical
● Yes, doing a Digital rectal examina on (DRE) is signi cant for this case because through DRE, the color of stool can
Therapeu cs 36th edi on (PDF
be examined directly which can help localize the level of bleeding.
version) pages 1819
Will you admit this pa ent in the hospital or Philippine Consensus Statements on
manage as an outpa ent? Jus fy. the Management Of Non-Variceal
● I will admit the pa ent in the hospital because I consider this as a case of Pep c Ulcer Disease secondary to Chronic Upper Gastrointes nal Bleeding:
NSAID use with Chronic blood loss. The pa ent reported dizziness and nausea which are indica ons of signi cant 2012
blood loss and upon physical examina on, pa ent presented with tachycardia. These ndings need quick The Pa ent History 2nd edi on. An
interven on, further work-up and careful monitoring. Evidence-Based Approach to
Di eren al Diagnosis. Chapter 36,
page 367

PREPARED BY: M. PLATERO, RN, MD, FPCP 4

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
Iden fy the problems of the pa ent General Management Speci c Management Reference
(Source, page no.)

Example # 1: Fever Control of temperature Paracetamol 500 mg/tab 1 tab every 4 hours as needed for fever XYZ, page 321
Example # 2: Noncompliance to Provide health educa on about hypertension and its complica ons. Stress
an hypertensive medica ons Behavior modi ca on to the pa ent the importance of regularly following the medica on ABC, page 123
schedule.
Ac ve ulcer Block acid produc on and promote healing Omeprazole 40 mg IV bolus The Washington Manual of Medical
Therapeu cs 36th edi on (PDF
Protect the lining stomach and small
Misoprostol 200 mcg QID version) pages 1825
intes ne
Harrison’s Principles of Internal
Medicine 20th edi on Chapter 317,
page 2228-2238

Behavior modi ca on Discon nue NSAID use

Philippine Consensus Statements on
the Management Of Non-Variceal
Upper Gastrointes nal Bleeding:
2012
The Washington Manual of Medical
Iron Dextran: prepara on 50 mg/ml of iron; Therapeu cs 36th edi on (PDF
Wait for hemoglobin level to calculate for total dose; version) pages 2267
Iron de ciency anemia Iron replacement therapy Test dose of 0.5 ml and observe pa ent for at least 1 hr for signs for
hypersensi vity; Harrison’s Principles of Internal
If no hypersensi vity reac on, infuse total dose Medicine 20th edi on Chapter 93,
page 686
Harrison’s Principles of Internal
Medicine 20th edi on Chapter 317,
Joint pain Manage pain Acetaminophen 325mg q4h as needed for joint pain
page 2228-2238

PLEASE READ: If you decide to admit this pa ent, kindly ll-up the admi ng order form. Otherwise, if you decide to manage the case as an
outpa ent, ll-up the outpa ent form following the SOAP format. When making the orders, relate it to the problems that you have iden ed in
your pa ent.

PREPARED BY: M. PLATERO, RN, MD, FPCP 5

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
ADMITTING ORDER FORM

COMPLETE ADMITTING IMPRESSION ● Pep c Ulcer Disease secondary to Chronic NSAID; To consider Iron De ciency Anemia secondary to Chronic blood loss

ADMITTING ORDER Ra onale Reference

(source, page no.)

Admit pa ent under the service of Doctor Juan dela Cruz

Secure consent
● Admit the pa ent in a private room The pa ent presented with tachycardia and dizziness which are alarm The Pa ent History 2nd edi on.
Decide which AREA/SECTION IN THE
signs and symptoms of GI bleeding. An Evidence-Based Approach to
HOSPITAL you will admit the pa ent
Di eren al Diagnosis. Chapter 36,
e.g Admit pa ent in a private room
page 367
● IVF PNSS 1L 120c/hr This would act as a source of hydra on and electrolytes for the IM Pla num Third edi on page 79
Choose which INTRAVENOUS FLUID is pa ent.
appropriate for the pa ent; show the Solu on
solu on in compu ng the rate cc/hr = total infusion volume/total me of infusion
e.g. IVF PNSS 1 liter at 80cc/hr cc/hr = 1000 mL/8hrs
cc/hr = 125 cc/hr
● Light meals un l midnight; NPO 6-8 hours before This is to prepare the pa ent for endoscopy. Philippine Consensus Statements
Iden fy appropriate DIET plan for this
endoscopy on the Management Of Non-
pa ent
Variceal Upper Gastrointes nal
e.g. NPO Bleeding: 2012 pages 3-5
● Complete blood cell (CBC) count This is to detect anemia and assess degree of bleeding. The Washington Manual of
Medical Therapeu cs 36th edi on
● Blood type This is in prepara on for blood transfusion.
(PDF version) pages 1820 & 1821
● Rh-factor This is in prepara on for blood transfusion.
● Fecal occult blood test This is to detect presence of microscopic blood in the stool.
Protocol for Diagnosis and
● Urinalysis This is to assess degree of hydra on, condi on of the kidney and Treatment of Pep c Ulcer in
genitourinary tract, and if there is a presence of infec on. Adults. American Interna onal
Iron in blood serum This is to assess the degree and type of anemia. Health Alliance. page 3
●
● Re culocyte count This is to measure e ec ve erythropoiesis.
Iden fy the DIAGNOSTICS TESTS that
● Blood sugar This is to assess there are co-exis ng condi ons.
you think are appropriate and necessary

PREPARED BY: M. PLATERO, RN, MD, FPCP 6

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
you think are appropriate and necessary Department of Internal Medicine
for the management of this case; be ● Crea nine, BUN, Liver func on tests
speci c ● Urease Test
e.g. complete blood count
● Esophagogastroduodenoscopy (EGD)
● Histolological and cytological evalua on of biopsy
● Omeprazole 40 mg IV bolus BID
● Misoprostol 200 mcg QID
This to assess renal and hepa c condi on.
This is to assess a co-exis ng H. pylori infec on
This permits direct visualiza on of the mucosa and facilitates
photographic documenta on of a mucosal defect and ssue biopsy Henry’s Clinical Diagnosis and
to rule out malignancy (GU) or H. pylori. It is par cularly helpful in Management by Laboratory
iden fying lesions too small to detect by radiographic examina on, Method 22nd edi on Chapter 14,
for evalua on of atypical radiographic abnormali es, or to determine pages 174-177; Chapter 28, page
if an ulcer is a source of blood loss. 449; Chapter 30, pages 510, 512 &
This is to speci cally iden fy the loca on of the bleeding if there is a 513; Chapter 31 page 544
presence of carcinoma.
Harrison’s Principles of Internal
Medicine 20th edi on Chapter
317, page 2228
This is to block acid produc on and promote healing.
The Washington Manual of
Medical Therapeu cs 36th edi on
This is to protect the lining stomach and small intes ne. (PDF version) pages 1825, 2267

Harrison’s Principles of Internal

Iden fy the MEDICINES appropriate for ● Iron dextran Medicine 20th edi on Chapter 93,
this case Prepara on: 50 mg/ml of iron page 686; Chapter 317, page
Wait for hemoglobin level to calculate for total dose; 2228-2238
e.g. amoxicillin 500 mg/tab 1 tab TID This is a form of iron replacement therapy.
Test dose of 0.5 ml and observe pa ent for at least 1 hr
for signs for hypersensi vity;
If no hypersensi vity reac on, infuse total dose

● Acetaminophen 325mg q4h as needed for joint pain This to manage joint pain.

Iden fy what will you MONITOR and ● Vital signs monitoring every 4 hours This to monitor the degree of bleeding and the response to Harrison’s Principles of Internal
include the frequency; laboratory treatment. Medicine 20th edi on Chapter 93,
monitoring not included in this sec on page 686; Chapter 317, page
e.g. Vital signs monitoring every 4 hours 2228-2238

PREPARED BY: M. PLATERO, RN, MD, FPCP 7

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Iden fy other necessary
NONPHARMACOLOGIC INTERVENTIONS
e.g. insert NGT; referral to other services
or department
Department of Internal Medicine
● Discon nue NSAID use This is to prevent further damage to the gastric mucosa. Philippine Consensus Statements
on the Management Of Non-
Variceal Upper Gastrointes nal
Bleeding: 2012
● Endoscopic therapy Provides useful prognos c informa on, used as therapy in pa ents Harrison’s Principles of Internal
with acute hemorrhage Medicine 20th edi on Chapter 93,
page 686; Chapter 315, page
2194
● Intravenous hydra on/nutri on Conserva ve management for obstruc on Harrison’s Principles of Internal
Medicine 20th edi on Chapter 93,
● Nasogastric suc on Conserva ve management for obstruc on
page 686; Chapter 317, page
2236

OUTPATIENT FORM

DAVAO MEDICAL SCHOOL FOUNDATION HOSPITAL OUTPATIENT FORM - SOAP

S - SUBJECTIVE DATA (Answer in bullet format)
O - OBJECTIVE DATA (Answer in bullet format)
A – ASSESSMENT/DIAGNOSIS
P - PLAN
Diagnos c tests e.g. complete blood count Ra onale Reference
(source, page no.)

PREPARED BY: M. PLATERO, RN, MD, FPCP 8

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine

Medicines e.g. amoxicillin 500 mg/tab 1 tab TID Ra onale Reference

(source, page no.)

Other non-pharmacologic interven ons Ra onale Reference

e.g. Low salt, low fat diet (source, page no.)

PREPARED BY: M. PLATERO, RN, MD, FPCP 9

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine

PRESCRIPTION FORM
Name of Pa ent: REYNATO FERNANDEZ Age: 48 Sex: MALE
Address: DAVAO CITY Date: 11/09/2021

● This form will be used in prescribing

the drugs whether you admit the
pa ent or cater as an outpa ent case.
● Include the brand name that you
prefer to use. 1. Omeprazole (Omepron) 40 mg IV
● If you decide to admit the pa ent, sig. Infusion for 30 minutes once a day un l oral administra on is possible
give a prescrip on that will be u lized
by the pa ent for the next 24 hours. If 2. Misoprostol (Cytotex) 200 mcg/tab tab #1
you decide to manage the case as
outpa ent, give a prescrip on un l sig. 1 tab 4 x a day orally before meals
the next follow-up of your pa ent.
3. Iron Dextran (INFeD) 50 mg/ml of iron IV
Example: sig. Infuse 2 mL once a day un l oral administra on is possible

amoxicillin (Himox) 500mg/tab tab # 21 4.

sig. 1 tab 3 x a day orally for 7 days
sig.

5.
sig.

Doctor’s Name: Meevie Love Toledo

License #: 123 789
PTR #: 987 321

PREPARED BY: M. PLATERO, RN, MD, FPCP 10

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DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine

PREPARED BY: M. PLATERO, RN, MD, FPCP 11