Académique Documents
Professionnel Documents
Culture Documents
• Epigastric pain
• For the past 2/12
• Constant, constricting pain
• Radiation to the left chest
• a/w diaphoresis
• Relieved by rest
• No aggravating factor
• Been taking gastric medication
• Took GTN a day prior to admission
• Pain score 2-8/10
• Worsening pain for the past 1/52
• Melena
• Once daily for the past 1/52
• Tenesmus
• No fresh blood
• Not painful
• Vomiting
• Two times, day 4 of illness (3 prior to admission)
• Moderate amount
• Coffee ground stained
• Episode of giddiness after vomiting
• Reduced effort tolerance
• No chest pain
• No shortness of breath
• No palpitation
• No syncopal episodes
• No loss of weight
• No loss of appetite
PAST MEDICAL & SURGICAL
• IHD
• April 2017
• COROS + PCI done on April and July (2 vessel stenting)
• On Dual Antiplatelet Theraphy
• DM
• Was found to have DM during admission on April
MEDICATION LIST
85 year old
DM
SOCIAL HISTORY
Vital Sign:
Blood Pressure: 180/122 mmHg
Pulse Rate: 84 bpm, good volume, normal rhythm regularly regular
Respiratory Rate: 14 bpm
SpO2: 100%
Peripheral Examination:
Warm periphery, sallow looking palm, CRT <2s, no peripheral cynosis, no stigmata of
chronic liver disease.
There’s presence of conjunctival pallor and pale mucosa. Apart from that, good
hydration status, good mouth hygiene, no central cynosis, no glossitits and angular
stomatitis.
Abdominal Examination
Per rectal examination was done at the ED. No melena or blood was
noted.
Result RP (12/12/2017)
Parameters Result Reference value
Sodium 141 136-145 mmol/L
Potassium 4.3 3.5-5.1 mmol/L
Urea 4.9 3.2-7.4 mmol/L
Creatinine 111.9 63.6-110.5 mmol/L
Result LFT (11/12/2017)
Parameters Result Reference value
Albumin 35 35-50 g/l
Total protein 63 64-83 g/l
Bilirubin 10.5 3.4-20.5 umol/l
ALT 30 0-55 U/L
ALP 83 40-150 U/L
Amylase 100 25-125 U/L
Calcium 2.14 2.10-2.55 mmol/L
Corrected calcium 2.24 2.14-2.58 mmol/L
Phosphate 1.02 0.74-1.52 mmol/L
Magnesium 0.73 0.66-1.07 mmol/L
Result Coagulation Profile
(11/12/2017)
PYLORIC ANTRUM
Protective factor
1. Use of PPI