name:hassan ahmed adel saad 

group:448
z CASE HISTORY

INTERNAL MEDICINE

DIAGNOSIS: peptic ulcer

-PASSPORT DATA :-
z

1-name:natalia

2-age:3-year-old

3-address:lepova26

4-occupation:mildly tender
• -complaints:
z

1-fever

2- coffee-ground vomiting

3- abdominal pain.
-HISTORY:-
z

> family history of peptic ulcers

>medications :patient received two weight-appropriate
doses of ibuprofen and a dose of paracetamol, both
administered within an appropriate time interval in the
previous 24 hours for fever control.
>The patient had a positive medical history of upper
respiratory tract infections with febrile seizures and
interstitial pneumonia treated with antypiretics and
clarithromycin, respectively.
>The patient is allergic to cephalosporin and Augmentin
>Soon after hospitalization, the patient had a second
episode of coffee-ground vomiting.
-PHYSICAL FINDINGS:-
z
 -Epigastric tenderness - mild.
 -Bowel sounds - normal.
 -Rectal exam  show melena/guaiac+ stool from
occult blood loss.
 -tempreture:38.1c
 -weighed 15 Kg
 - measured 88 cm tall
 -Signs of peritonitis with perforation. 
 -Inspection: pale, weight loss, coating of tongue
 -Palpation: left or epigastric tenderness, pain
radiation, Vasilenko’s sign
 -Percusion: Mendel’s sign 
-PRELIMINARY DIAGNOSIS:
z

>inflammation of stomach wall

-DIFFERENTIAL DIGNOSIS :-
z
1-Acute Cholangitis 
  
2-Acute Cholecystitis and Biliary Colic 
  
3-Acute Coronary Syndrome 
  
4-Acute Gastritis 
  
5-Cholecystitis 
  
6-Chronic Gastritis 
  
7-Diverticulitis 
  
8-Emergent Treatment of Gastroenteritis 
  
9-Esophageal Rupture and Tears 
  
10-Esophagitis 
  
11-Gallstones (Cholelithiasis) 
  
12-Gastroesophageal Reflux Disease 
  
13-Inflammatory Bowel Disease 
-EVALUATION PLAN:-
z
1- CBC count 

2-biochemical blood analysis 

3- digestive endoscopy 

4-biopsy

5-H. pylori test
-EVALUATION RESULTS:-
z

1-Initial laboratory tests indicated anemia with

reticulocytosis (Hematocrit 29.7%, Hemoglobin 9.6
g/dl, reticulocytes 36/1000) and lower total protein
(55.2 g/L), characteristic of bleeding

2- upper digestive endoscopy with biopsy was

performed revealing a non-bleeding gastric ulcer at 2
cm from pylorus

3-H. pylori testing was negative.

-Clinical examination:- 
z

>revealed general malaise, pallor, fever,

pharyngotonsillar congestion and productive cough,
normal breath sound, a distended and mildly tender
abdomen moving normally with respiration and
normal stool. The patient weighed 15 Kg and
measured 88 cm tall.
-CLINICAL DIAGNOSIS:-
z

-PEPTIC(gastric) ULCER DISEASE
-TREATMENT :-
z

1-glucose and electrolytes administerating in order to

compensate for fluid loss

2-proton pump inhibitor (esomeprazole 10 mg/day)

for 2 months.
-RECOMINDATIONS:
z

1-stop taking cephalosporin and Augmentin

drugs.

2- taking fruits are good and contribute beneficial

fiber and antioxidants. Berries, apples, grapes,
and pomegranates are among the best choices
for ulcer healing polyphenols
-investigations interpretation:-
z

1-Remaining laboratory results were normal

2-normal coagulation tests