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    Family History: Case #2

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    Hikufe Jesaya
    A 58-year-old woman presented with a 2-month history of epigastric pain, weight loss, nausea, and vomiting. Physical examination revealed significant epigastric pain. Gastroscopy found a 1.2+1.5 cm ulcer in the pyloric part with a punched-out base. Laboratory tests showed anemia and elevated inflammatory markers. The patient was diagnosed with a peptic ulcer.

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    Family History: Case #2

    Uploaded by

    Hikufe Jesaya
    42 views4 pages
    A 58-year-old woman presented with a 2-month history of epigastric pain, weight loss, nausea, and vomiting. Physical examination revealed significant epigastric pain. Gastroscopy found a 1.2+1.5 cm ulcer in the pyloric part with a punched-out base. Laboratory tests showed anemia and elevated inflammatory markers. The patient was diagnosed with a peptic ulcer.

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    ulcer

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    A 58-year-old woman presented with a 2-month history of epigastric pain, weight loss, nausea, and vomiting. Physical examination revealed significant epigastric pain. Gastroscopy found a 1.2+1.5 cm ulcer in the pyloric part with a punched-out base. Laboratory tests showed anemia and elevated inflammatory markers. The patient was diagnosed with a peptic ulcer.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    42 views4 pages

    Family History: Case #2

    Uploaded by

    Hikufe Jesaya
    A 58-year-old woman presented with a 2-month history of epigastric pain, weight loss, nausea, and vomiting. Physical examination revealed significant epigastric pain. Gastroscopy found a 1.2+1.5 cm ulcer in the pyloric part with a punched-out base. Laboratory tests showed anemia and elevated inflammatory markers. The patient was diagnosed with a peptic ulcer.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    Case #2

    A 58-year-old woman was referred to a hospital from primary care provider


    due to consistent discomfort and significant weight loss. She looked for a PCP’s
    advice as she had a tarry stool in the early morning which she had never experienced
    before. She presented with a 2-month history of burning pain in the epigastric
    abdomen and chest which radiated toward her back. Her pain worsened after drinking
    coffee, and was relieved after taking antacids. She had previously lost 10 pounds in 2
    months due to decreased intake caused by the feeling of bloating, early fullness and
    stomachaches between meals. She also reported nausea and vomiting. She expressed
    concern especially because the food appeared undigested when she vomited. She also
    reported doubling her NSAID intake due to increased knee pain. She looked pale and
    exhausted when she entered the clinic.
    Upon physical examination, there is a significant pain in the epigastric region.

    Medical history
    1. Diabetes Mellitus and hypertension diagnosed 6 years ago.
    2. No surgical history.

    family history
    1.Mother died from gastric cancer 10 years ago.
    2.One son alive and well at age 29.
    3.One daughter at age 35, alive and has recurrent Gastritis.
    Pertinent social history
    1.Has worked full-time as a nurse during 30 years.
    2.Divorced with her husband 20 years prior, raised 2 children by herself.
    3.Hobbies include drinking, eating spicy food, watching dramas and talkshow.
    4.No smoking

    Vital Signs and Measurements


    1.BP: 134/79 mm Hg
    2.HR: 76 bpm
    3.RR: 15 b / min
    4.Temperature: 36.1 ℃
    5.Pulse oxygenation: 99%
    6.Height: 167 cm
    7.Weight: 58.2 kg

    Gastroscopy Report:
    Oesophagus oesopahageal junction were normal. Cardia is normal. In pyloric
    part there is a ulcer size 1.2 +1.5 cm. with a punched-out ulcer base and whitish
    fibrinoid exudates. Duodenum is normal.

    Laboratory results:

    WBC 5.9 x 10ˆ9/l(4.00 – 10.00)


    (12.1 – 15.1
    Hb 11.0g/dl
    g/dl)
    248 x
    Platelets (150 – 400)
    10ˆ9/l
    CRP 3.4 mg/l (0 – 5 mg/l)

    Urea and
    Electrolytes:
    (135 – 147
    Na 137 mmol/l
    mmol/l)
    (3.3 – 5.0
    K 3.5 mmol/l
    mmol/l)
    (99 – 113
    Cl 96 mmol/l
    mmol/l)
    (2.5 – 7.0
    Urea 3.3 mmol/l
    mmol/l)
    (60 – 12
    Creat 32 umol/l
    umol/l)
    WBC 5.9 x 10ˆ9/l(4.00 – 10.00)
    Urea breaht test:Positive Negative

    Liver Function
    Test:
    (3 – 18
    Total Bili 7 umol/l
    umol/l)
    Conjugated Bili 3 umol/l (0 – 5 umol/l)
    Total Protein 74g/l (60 – 80 g/l)
    ALP 66 U/l (30 – 120 U/l)
    GGT 7 U/l (5 – 35 U/l)
    AST 41U/l (5 – 45 U/l)
    ALT 25U/l (5 – 45 U/l)
    Thyroid
    Function Test:
    (10.3 – 21
    Free T4 19.7pmol/l
    pmol/l)
    (0.35 – 4.50
    TSH 1.8 mIU/l
    mIU/l)

    (2.12 – 2.65
    Calcium 2.13mmol/l
    mmol/l)
    Albumin 27 g/l
    (0.8 – 1.4
    Phosphate 0.9 mmol/l
    mmol/l)
    Ig G and M to H.
    29,1 Negative
    pylori
    HIV Negative

    Urine MCS:
    Leucocytes Trace
    Bacteria Absent

    Stool MCS:
    WBC 5.9 x 10ˆ9/l(4.00 – 10.00)
    Brown Unformed

    Erythrocytes Negative
    Not
    Parasites
    observed
    Aerobic Not
    organisms isolated
    Calprotectin 31 0-50
    C difficile toxin
    Negative
    A
    C difficile toxin Negative

    Chest X-ray:

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