Bleeding peptic ulcer disease case study

CASE STUDY: PEPTIC ULCER DISEASE INITIAL HISTORY: ➢ 58 year old male complaining of 3 week history of increasing epigastric pain ➢ Has had dyspepsia in past and took “Tums” but this is much worse and only partially relieved by chewable antacids Question 1: What is your differential diagnosis based on this limited history? Question 2: What questions would you like to ask this patient about his symptoms? ADDITIONAL HISTORY: ➢ Pain has a burning quality and is relieved with eating, especially drinking milk, but returns about 2 hours after eating ➢ Denies radiation of pain to back, melena, hematemesis, or fever ➢ Denies early satiety, anorexia, or weight loss ➢ Denies fatty food intolerance or change in stools ➢ Denies jaundice, increased abdominal girth, or easy bruising ➢ No shortness of breath or pain with exercise Question 3: What questions would you like to ask about his recent and past medical history? MORE HISTORY AND PHYSICAL EXAMINATION: ➢ Has been taking ibuprofen for 2 months for a knee injury ➢ Drinks approximately 3 mixed drinks a day and smokes 1 pack of cigarettes a day ➢ Has had a recent job change with increased stress and feels tired lately ➢ No recent history of illness or hospitalization ➢ Has a history of mild hypertension that is treated with diet ➢ On no prescription medications and has no known allergies ➢ Thin white male in no acute distress ➢ T = 37 C orally; P = 90; RR = 16 and unlabored; B/P 148/96 right arm (sitting) HEENT, Neck: ➢ PERRLA, fundi without vascular changes ➢ Pharynx clear ➢ No thyromegaly ➢ No bruits or adenopathy Lungs, cardiac: ➢ Lungs clear to auscultation and percussion ➢ Cardiac with RRR with no murmurs or gallops Abdomen: ➢ Abdomen not distended, bowel sounds present ➢ Liver percusses to 8 cm at midclavicular line, one fingerbreadth below right costal margin ➢ Epigastric tenderness without rebound or guarding and spleen is not palpable Rectal: ➢ No hemorrhoids seen or felt ➢ Prostate is soft and not enlarged ➢ Stool grossly normal but weakly positive for blood Extremities, Neurological: ➢ No edema and pulses full with no bruits ➢ Oriented X 4 with normal strength, sensation, and DTR Question 4: What are the pertinent positives and negatives on the physical exam? Question 5: What initial diagnostic tests would you obtain? LABORATORY RESULTS: ➢ Chemistries including calcium and BUN and Creatinine are normal ➢ WBC = 9000 with normal differential and HCT is 45% ➢ Liver function tests including bilirubin are normal ➢ Serum and urine amylase and lipase are normal ➢ EKG shows normal sinus rhythm without evidence of ischemic changes Question 6: What test should be chosen to best evaluate for peptic ulcer disease in this patient? ENDOSCOPY RESULTS: ➢ Normal esophageal mucosa ➢ Gastric mucosa with superficial gastritis and no ulceration ➢ 0.5 cm duodenal ulcer with evidence of recent bleeding but no acute hemorrhage and no visible vessels in the ulcer crater and H. Pylori testing is positive Question 7: What management would you recommend? Brashers, V. L. (2006). Clinical applications of pathophysiology: An evidence-based approach. St. Louis, MO: Mosby. ...