Admission Conference

Ardie S. Rama
Gastroenterology
February 9, 2011
 A.L.
57 years old, Male

Chief Complaint:
Hematemesis and Melena
 History of Present Illness
2 years PTA • Burning epigastric pain (7-8/10)
• Relieved by food intake
• Occurs 1x/month
• No nausea, vomiting, anorexia,
night distress
• No consult
• Medication: Omeprazole
20mg/tab, OD-BID
 History of Present Illness
1 years PTA • Increase in frequency: 5x/month
• Medication: Omeprazole
20mg/tab, 1 tab BID
• Still no consult
 History of Present Illness
4 months PTA • vomiting of previously ingested
food amounting 1 cup once a
week
• Still no consult

2 months PTA
• Weight loss
• Loss of appetite
 History of Present Illness
2 weeks PTA • Change in bowel movement
(once a week)
– Stool solid, dark colored and foul
smelling
• No consult done
 History of Present Illness
10 days PTA • Hematemesis and Melena
• Consult done
• Dx: not disclosed
• Medications:
– MgOH TID for 1 week
– Ranitidine BID for 1 week
– Buscopan TID, prn for pain
 History of Present Illness
2 days PTA • Persistence of Symptoms
• Another consult at a local
hospital
• Medication: Ranitidine
• Advised Endoscopy
• Transferred to our institution

• Admission
 Review of Systems
• General: (-) fever, (-) easy ftigability
• Skin: (-) hair loss, (-) pruritus, (-) rash
• Pulmonary: (-) dyspnea, (-) cough, (-) hemoptysis, (-) wheezing
• Cardiac: (-) chest pain, (-) PND, (-) orthopnea, (-) edema
• Muscular: (-) joint pains, (-) joint stiffness, (-) limitations in motion,
(-) spasticity, (-) flaccidity
• Urinary: (-) dysuria, (-) hematuria, (-) increased in frequency
• Endocrine: (-) nocturia, (-) polydipsia, (-) polyphagia
• Neurologic: (-) seizures, (-) sensory deficits, (-) mental changes
• Psychiatric: (-) anxiety, (-) depression, (-) nervousness, (-) delusions
 Past Medical History
• Not known Hypertensive
• Not known diabetic
• (+) Appendectomy 1972
• (-)TB, Asthma, Pneumonia
• (+) Allergy –Penicillin
 Family History
• (+) HTN - father
• (-)DM
• (-) Asthma, Thyroid disorders, Cancer
 Personal and Social History
• Mixed diet , mostly fish and vegetables
• (+) smoker 30 pack years
• (+)alcoholic beverage drinker 8 bottles beer
everyday for 25 years
• Denies illicit drug use
 Physical Examination
• Conscious, coherent, not in cardiorespiratory distress
• BP Supine: 130/70mmHg HR 88 bpm, regular RR 24 cpm, regular
T= 36.5 C O2sat 97%
• Estimated Ht:157.5cm Estimated Wt: 59kg BMI:23.8
• Warm moist skin, no active dermatoses, no jaundice
• pale palpebral conjunctivae, anicteric sclerae, pupils 2-3mm ERTL
• Funduscopy: (+) ROR, A:V ratio 2:3, (-) retinopathy
• Nonhyperemic EAC, intact tympanic membrane no nasoaural
discharge, noncongested turbinates, dry lips, moist buccal
mucosa, non- hyperemic posterior pharyngeal wall, tonsil not
enlarged
 Physical Examination
• Supple neck, no palpable cervical lymph nodes, thyroid gland
not enlarged
• Symmetrical chest expansion, no chest deformities, no
retractions, clear breathsounds
• Adynamic precordium, apex beat at the 5 th LICS MCL, no
heaves, lifts, thrills, S1>S2 at the apex S2>S1 at the base, no
murmur
• Flabby abdomen, (+) appendectomy scar RLQ, normoactive
bowel sounds, soft, no tenderness, no palpable masses, liver
7-8cms MCL with firm smooth edge, spleen tip not palpable,
Traube’s space not obliterated
• Pulses full and equal, no cyanosis, no edema, no finger/joint
deformities
 Neurologic Examination
• Alert, oriented to 3 spheres, GCS 15
• Pupils 2-3mm ERTL, isocoric, no ptosis, EOM intact
• Fundoscopy: (+) ROR, (-) retinopathy
• No facial asymmetry, V1-V3 intact, no shallow nasolabial fold
• Can raise eyebrows, smile, puff cheeks
• Can turn head, shrug shoulders, tongue midline on
phonation
• Can do APST and FTNT
• MMT 5/5 on UE and LE, DTR 2+ on all extremities
• (-) Nuchal ridigity,in all directions, (-) Babinski
 Assessment
• UGIB probably secondary to PUD
• t/c Gastric malignancy
 Diagnostic Plans
• CBC
• PT, aPTT, INR
• Na, K
• Barium enema/Endoscopy
• Urea Breath Test
 Therapeutic Plan
• Esomeprazole 20mg/tab, 1 tab OD
THANK YOU!