CASE PRESENTATION

East Avenue Medical Center Female Surgical Ward Group D

Background of the case:
Upper Gastrointestinal bleeding refers to hemorrhage in the upper gastrointestinal tract. The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the diaphragm near the splenic flexure of the colon.

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. PTB. or Cancer. Ô Patients paternal uncle was operated in the esophagus of unknown reason and that currently patient had no voice.FAMILY HISTORY Ô Father had a stroke. Ô No known heredo-familial diseases such as BA. DM.

OB HISTORY Ô G2P2 (2002) Ô Menarche at 12 years old Ô Consuming 2 pads a day Ô Menstruation last from 5-6 days duration Ô Regular monthly interval .

DIETARY HISTORY Ô Patient not taking any vitamins as Vit C Ô fond of salted foods Ô fond of smoked foods Ô fond of canned foods Ô (+) smoker Ô (+) alcohol drinker .

surgeries. or Cancer. not known to have DM. or allergies to foods and medications. Ô No previous hospitalization. PTB. BA. HPN.PAST MEDICAL HISTORY Ô As above. .

relieved by food but eventually recurs 2-3 hours after associated with early satiety. Patient also noted gradual weight loss approximately 40%.HISTORY OF PRESENT ILLNESS Ô 5 months PTA ² patient had epigastric pain radiating to the back. Consult done at Health Center and was prescribed with antacid taken TID for 2 weeks with relief of symptoms. Patient self-medicated with Loperamide to relief self of LBM. greenish LBM of 4 episodes a day approximately ½ cup per episode that lasted for 3 days. .

TID. the symptoms recurred after the patient completed her medications.Ô 1 ½ month PTA ² Patient started to have 4-5 times vomiting usually occuring in the late afternoon with persistent epigastric pain and heartburn. Given Xeloid Gel. patient consulted to a private MD and was told that she has gastritis. But 1 week later. . Ô 5 weeks PTA ² With persistence of symptoms. Gasmed tab TID and Omeprazole 20mg OD with relief.

epigastric pain but no melena. Persistence prompted consult hence admission.Ô 2 weeks PTA ² Patient consulted at TALA Hospital and was prescribed with Omeprazole OD. Self treated with Maalox 1tbsp OD and Omeprazole 20mg OD. Ô 3 days PTA ² Patient had coffee ground post prandial vomiting occuring 5 times a day with anorexia. . Maalox 1tbsp QID and Ofloxacin 200mg BID for 1 week for her UTI.

PHYSICAL EXAMINATION GENEREL SURVEY: Ô Conscious Ô Coherent Ô Ambulatory Ô No respiratory distress Ô Pale and weak looking Ô Slightly cachectic .

75 kg/m2 .55m Ô Weight: 45 kg Ô BMI: 18.1°c Ô Height: 1.Ô Blood Pressure: 90/60 mmHg Ô Cardiac Rate: 90 bpm Ô Respiratory Rate: 22 cpm Ô Temperature: 37.

HEENT: Ô Pale palpebral conjunctiva Ô Anicteric sclera Ô No nasoaural discharge Ô No tonsillopharyngeal congestion Ô Noted eyes to be slightly protruded Ô (+) Coffee Ground output per NGT .

NECK: Ô Supple Ô No neck vein engorgement Ô No palpable lymphadenopathies Ô (-) supraclavicular Ô Lymphadenopathy .

HEART: Ô Adynamicprecordium Ô Apex beat at 5th ICS MCL Ô Regular heart rate Ô No murmur .

ABDOMEN: Ô Flat and soft Ô (+) ovoid fixed non mobile smooth mass at epigastric area with tenderness Ô Normoactive bowel sound .

EXTREMITY: Ô No gross deformity Ô Full and equal pulses Ô No edema Ô Pale nail beds .

DRE: Ô (+) skin tag at anus Ô Good sphincter tone Ô Empty rectal vault Ô Smooth wall with no mass Ô Noted dark brown stool per examining finger .

ROS: Ô (-) orthopnea Ô (-) easy fatigability Ô (-) palpitations Ô (-) PNO Ô (-) chest pain Ô (-) chest discomforts Ô (-) diarrhea Ô (-) constipation .

Bleeding Gastric mass .Assessment: Upper Gastrointestinal Bleeding probably secondary to: 1. BPUD 2.

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biopsy: Ô Gastric Adenocarcinoma Ô Poorly differentiated with signet ring features Ô Negative for Helicobacter pylori .CYTOLOGY REPORT DIAGNOSIS: Gastric mucosa.

SPECIMEN: Gastric mucosa CLINICAL DIAGNOSIS AND HISTORY: Ô Upper gastrointestinal bleeding probably secondary to gastric mass probably malignant .

irregular. Ô No Helicobacter pylori organisms are evident on Giemsa stain. Ô Sections show gastric tissues with involvement of a neoplasm seen in sheets.GROSS AND MICROSCOPIC DESCRIPTION: Ô Rectered specimen labeled ´gastric mucosaµ consist of 8 cream-whiteblack. soft tissue fragments. .

GASTRIC ADENOCARCINOMA Ô It is also called malignant tumor of the stomach. Ô Risk factors include: chron .

LABORATORY RESULTS HEMATOLOGY COMPONENTS Hemoglobin Hematocrit RESULT 70 0.48 for female adults SI UNITS gm/L gm/L .210 NORMAL VALUES 120-140 for female adults 0.38-0.

ANATOMY AND PHYSIOLOGY .

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PATHOPHYSIOLOGY .

O .DRUG STUDY Ô Aminoleban 500cc Ô Omeprazole 40mg Ô Ferrous Sulfate (TID) P.

Nursing Care Plan .

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