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Scenario 4, The 50-year-old female known case of DM, HTN and OA presented…
Scenario 4
Relevant Questions
Onset and duration: Timing helps differentiate acute conditions (e.g., gastritis, pancreatitis) from
chronic ones (e.g., peptic ulcer disease).
Character: Different types of pain may suggest specific diagnoses, such as burning pain in gastritis or
colicky pain in gallstones.
Severity: severe pain may signal perforation, while mild pain may suggest gastritis.
Aggravating or relieving factors: worsened by food may indicate peptic ulcer disease, relieved by antacids may suggest GERD
Associated symptoms: nausea, vomiting, or changes in bowel habits can indicate gastrointestinal
involvement or complications like obstruction.
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Medication: Some medications (e.g., NSAIDs) can cause gastritis or exacerbate GI symptoms
Diet: What have you been eating lately? Any specific dietary habits? Dietary habits such as spicy foods aggravating gastritis or allergens gluten intolerance).
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Lifestyle: Smoking and alcohol use increases the risk of GI conditions e.g peptic ulcer disease,
pancreatitis.
Physical Examination
General appearance: Assess overall appearance, signs of distress, and nutritional status. 1)Signs of distress indicates acute conditions like perforated ulcer or pancreatitis.2)Malnutrition: Suggestive of chronic GI disorders such as malabsorption syndromes.
Vitals: Elevated temperature Points towards infectious causes like gastritis or cholecystitis,
Hypotension can be indicative of hypovolemia from GI bleeding.
Abdominal examination: Tenderness and guarding suggest inflammation as seen in pancreatitis or
appendicitis, Rebound tenderness indicates peritonitis from perforation, such as a perforated peptic ulcer, Masses or organ enlargement could indicate tumors or organomegaly associated with conditions like
pancreatic cancer or liver cirrhosis, Murphy's sign if Positive sign suggests cholecystitis.
Skin examination: Look for signs of jaundice, rash, or other dermatological issues. Jaundice suggestive of liver or biliary tract pathology, like hepatitis or obstructive jaundice.
Cardiovascular and respiratory: Evaluate heart sounds, lung sounds, and signs of respiratory distress. Tachycardia indicates systemic illness or hypovolemia from GI bleeding. 7)Respiratory distress: May suggest complications such as aspiration pneumonia.
Neurological: Altered mental status Indicates severe illness, hepatic encephalopathy from liver failure,
or neurological complications such as brain metastases.
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Extremities: peripheral edema can be indicative of systemic conditions like heart failure or
hypoalbuminemia from malnutrition.
Management Plan
For Dyspepsia
Non Pharmacological: Healthy eating, weight reduction, smoking cessation, avoidance of precipitants, elevation of head end of the bed etc.
Pharmacological: Empirical full dose of PPIs once daily for 4 weeks or H2RA if not responsive to PPIs.
In case of H. Pylori : PPIs 20mg+Amoxicillin 1gm+Metronidazole 400 mg+Clarithromycin 500mg BD for 14 days (if Penicillin allergic then PPIs+Clarithromycin+Metronidazole or PPIs+Bismuth+Metronidazole+Tetracycline 500mg QID for 10-14 days.
As patient is known case of arthritis continue PPIs with COX Inhibitors.
For Peptic Ulcer Disease:
Full dose of PPIs or H2RA for 8 weeks.
For H. Pylori eradication 2 weeks washout after PPIs before doing urea breath test or stool antigen for H. Pylori.
As patient is diabetic add prokinetic for him and for those who dont respond to first 2 treatment lines.
Differential Diagnosis
- Dyspepsia
- Peptic ulcer disease/GERD
Relevant Investigations
- CBC to check anemia.
- Urea Breath Test/ Stool Antigen for H. Pylori.
- Endoscopy in case of red flags e.g dysphagia, upper abdomen mass, with history of weight loss and
age more than 55 years
The 50-year-old female known case of DM, HTN and OA presented with complain of Epigastric pain for 2 weeks
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