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Published on : Oct 28, 2018 | Views : 2851 | Downloads : 4

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Slide 1-

Case presentation Done & Presented by : Dr.Hamad Al-Ablani Supervised by : Dr.Ezeldin ( Medical consultant ) Second MOC : Dr.Khadijah
Slide 2-

Chief Complaint Black stool Dizziness 4 days
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History of Present illness 52years old Female, known case of Diabetes mellitus type 2 on OHA , hypertension , Bronchial asthma , status post mitral valve replacement on warfarin ,CKD .. presented to ER with complaining of passage of black stools 4 days . The melena started 4 days ago with sudden onset , one to two times per day , soft in consistency , black offensive stool with small amount . Its associated with epigastric pain , start one day before a melena , colicky in nature , radiated to back and there is partial improvement with analgesia .
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NO Hx of heartburn sensation , anorexia , nausea or vomiting . NO HX of Diarrhea or constipation . No HX of dysphagia or hematemesis . NO HX of jaundice or abdominal distension . No HX of fever , night sweating , or weight loss . NO HX of raw milk ingestion . NO HX of contact with sick people or recent travel NO HX of SOB , chest pain , orthopnoea ,PND ,or LL oedema . NO HX of easy bruising or ecchymosis . No HX of skin rash or pigmentation or joints pain . NO HX of polyuria, dysuria or GU symptoms
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Past History No previous surgeries History of blood transfusion 3 MONTHS ago . Vaccination history uncelar .
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DRUG HISTORY Warfarin , 4mg PO Q24H Atenolol , 100 mg PO Q24h Atorvastatin , 20mg PO Q24H Esomeprazole , 40mg PO Q24H amlodipine , 10mg PO Q24H Aspirin , 81mg PO Q24H Paracetamol , 500mg PO Q6H PRN
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Family History 3 sister , 4 brothers ( DM,HTN ) No history of similar presentation in the family . No history of malignancy in the family .
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Social History Married with three sons and two daughters . Not smoker , Not alcoholic . No history of drug abuse No history of recent travel No history of Contact with animals or sick patients . Allergic History Not known to have any allergies from food or drugs .
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General Examination General Conscious, alert, oriented to T/P/P. Not on respiratory distress Looks pale, not cyanosed or jaundiced. She was in pain ( 6/10 ) Vitals T : 36.2 BP: 88/49 P: 103 RR : 26 O2 sat: 94% on RA
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Abdominal Exam Inspection Inverted umbilicus, no visible hernia, or dilated veins ,masses or Striae , mild distension , no skin discoloration with normal hair distribution . Palpation Soft , lax . Mild tenderness at epigastric area .
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No hepatosplenomegaly . Kidneys were not palpable No palpable masses , No Fluid thrill . No inguinal or axillary lymph node enlargement . Percussion No Shifting dullness . Auscultation +ve bowel sounds , no bruits PR Examination : Black stool No perianal polyps/mass No anal fissure
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Cardiovascular Exam Inspection: No scars , No visible pulsation . No chest wall abnormalities Palpation - Apex beat at left 5th intercostal space, mid clavicular line . - No parasternal heave or palpable thrills . Auscultation S1 +S2 + 0 Audible click at mitral area .
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Chest Exam Inspection Patient setting in 45 degree , exposed from waist up No nasal canula or IV access . Not using accessory muscle . No scars , prominent veins or deformity. Symmetrical chest movement . Palpation Trachea is central . Equal chest expansion , front and back . Tactile vocal fremitus not increased or decreased
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CONT. – Chest exam Percussion Resonant bilaterally Auscultation Normal vesicular breathing with equal bilateral intensity of breath sounds with no added sound
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Investigations
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CBC U&E LFTs Coagulation Profile