General

Weekend Case Discussion - 31/7/16

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31 Jul 2016 - General
 

Middle aged gentleman, background of ex-intravenous drug user, chronic hepatitis C, previous perforated duodenal ulcer which was repaired, and alcohol dependancy, was admitted due to episode of  collapsed and hypothermia of around 35 celcius. Patient was a very vague historian, with some compliants of intermittent coffe ground vomiting and few episodes of malaena last week. Patient has been drinking around 12-14 unit or alcohol everyday since 3 weeks ago. No other symptoms. Episode of collapse was due to general weakness, with no loss of conscious. Patient's temperature was back to normal in emergency department. PR examination shows FOB positive. Hb was 3.3, and the repeat sample was 3.2, significant drop from 14.1 few months ago !!!! INR was 1.9, with low albumin, but normal platelet level and glucose level, only very minimal deranged liver function, mixed pattern. He did has normal U/S abdominal 4 years ago. What is your working diagnosis and differential diagnosis ?? What is your managment plan?  


@Ziwei Xie, to correct the tiny mistake “PR examination normal, and FOB positive”, usually the instant FOB test was done together with PR exam. Erected chest x –ray showed NO air under diaphragm, with a normal PFA. Working diagnosis is bleeding gastric / duodenal ulcer, with the potential differential diagnosis of Varices bleeding (given patient’s background medical condition, high INR, low albumin). Patient was given 3 unit of blood transfusion, IV PPI infusion. An urgent OGD was performe...
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PR examination shows FOB positive lol. That doctor has got really good eyesight! My working diagnosis will be return of the perforated duodenal ulcer. MY management is to start IV omeprazpole, blood transfusion, erect x-ray.Initiation of fluid resuscitation should start as soon as the diagnosis is made. Insertion of a nasogastric tube to decompress the stomach/ Should prepare for OGD KIV emergency laparotomy. If perforated i.e air under diaphragm. just go for emergency laparotomy. If no perfora...
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