primary care case *dyspepsia*
DESCRIPTION
Primary Care Case *Dyspepsia*. Ventura, Rolando Jr. Verdolaga , Ria Mae Villanueva, Maureen Elvira Villanueva, Roel Visperas , Joana Francesca. Background. Dyspepsia is a term used to describe a constellation of symptoms arising from the upper abdomen . - PowerPoint PPT PresentationTRANSCRIPT
Primary Care Case
*Dyspepsia*Ventura, Rolando Jr.Verdolaga, Ria Mae
Villanueva, Maureen ElviraVillanueva, Roel
Visperas, Joana Francesca
BackgroundO Dyspepsia is a term used to describe
a constellation of symptoms arising from the upper abdomen.
O It is a subjective feeling most often described by patients as “upper abdominal discomfort”, “pain”, “aching”, “bloatedness”, “fullness”, “burning” or “indigestion”.
General DataO B.T.O 51/M, MarriedO Tayuman, ManilaO Driver
O CC: Epigastric Pain (“sinisikmura”, “dumidighay”)
History of Present Illness
2 months PTC:O throbbing epigastric painO pain severity of 8/10O associated with loss of appetite, dizziness
and nauseaO pain temporarily relieved by intake of foodO sought consult at a private clinicO hepatitis titers and CXR were normalO diagnosis of Urinary Tract Infection based
on urinalysis
2 months PTC
History of Present Illness
2 months PTC:Ultrasound findings:
O Hepatic MassesO 2.09 x 1.8 x 1.8 cm Right LobeO 1.26 x 1.12 x 1.08 cm Left LobeO 8.33 x 6.45 x 6.35 cm Caudate Lobe
O Impression:O Hepatic New GrowthO Gallbladder polypO Suspect: para-aortic node enlargement O Spleen, kidneys, urinary bladder, prostate normal
2 months PTC
History of Present Illness
3 weeks PTC:O consulted a different private clinic
regarding persistence of symptoms.O tumor marker was requestedO prescribed Tramadol HCl 50 mgO self-medicating with Mefenamic Acid
and Herbal medication for the kidneys (Uniherb Kidney Care).
2 months PTC 3 weeks PTC
History of Present Illness
1 week PTC:O patient noted tarry stools (melena)O 1 episode of blood-streaked stool
(minimal)O patient also noted recurrence of pain
on the left lower quadrant radiating to the back
2 months PTC 3 weeks PTC1 week PTC
History of Present Illness
2 days PTCO tumor marker levels showed normal
AFP levelsO prescribed with Omeprazole 20mg
OD for 3 weeksO patient was then referred to PGH for
liver biopsy.
2 months PTC 3 weeks PTC1 week PTC2 days PTC
Review of SystemsO (+) weight loss
O 6% in 2 monthsO (+) loss of appetiteO (-)feverO (-) chillsO (-) headacheO (-) blurring of visionO (-) hematemesisO (-) hemoptysisO (+) exertional dyspneaO (-) OrthopneaO (-) PND
O (-) chest painO (+) nocturiaO (-) frothy urineO (-) dysuriaO (-) hematuriaO (-) retentionO (-) polyphagiaO (-) polydipsiaO (-) polyuriaO (+) melenaO (-) hematochezia
Past Medical HistoryO Pneumonia with pleural effusion-
1999O Chicken pox- 2008O No allergies
Personal/Social HistoryO Former smoker (20 pack-years)
O stopped in 1996O Occasional alcoholic beverage drinkerO History of illicit drug use
O Marijuana: 1982-2000, occasional O Shabu: 1984-1999, occasional
O Has had 3 sexual partners before marriage, non-promiscuous
O Diet: usually eats fish, vegetables and fruits. Does not eat beef/pork often
Family History
Psychosocial Impact of Illness
Patient was deeply worried by the cost of diagnostic procedures and treatment O However, when probed on the financial
capability to have the needed tests done, he shared that he may be able to get support from his employer.
O He was also referred to Medical Social Services for financial support.
Px was also worried about the presence of liver masses on ultrasound and worries that it may be an indication of a malignancy.
Physical ExaminationO Awake, alert, cooperative, not in
cardiorespiratory distressO BP: 110/80O PR: 80 beats per minuteO RR: 16 breaths per minuteO Temperature: 35.6 degree CelsiusO BMI: 30
Physical ExaminationO HEENT
O pink conjunctivaeO icteric scleraeO trachea is midlineO (-) nasoaural dischargeO (-) neck vein engorgementO (-) cervical lymphadenopathyO (-) anterior neck mass
Physical ExaminationO Chest/Lungs
O equal chest expansionO clear breath soundsO no adventitious breath soundsO (-) wheezesO (-) cracklesO (-) rhonchi
Physical ExaminationO CVS
O normal rate and rhythmO distinct S1 and S2O no murmurs
O AbdomenO DistendedO hyperactive bowel soundsO tenderness on the epigastric, periumbilical
and hypogastric areas on light and deep palpation
O Liver span 6cm
Physical ExaminationO Genitourinary
O no pain on kidney punchO Digital rectal exam
O no blood on examining fingerO prostate not enlargedO no massesO good sphincter tone
Physical ExaminationO Skin/ Extremities
O pink nail bedsO full and equal pulsesO (-) edemaO (-) cyanosis
O Muscle strength normal on all 4 extremities
Differential DiagnosisDisease Rule In Rule Out
Peptic Ulcer Disease
Throbbing epigastric pain relieved by eating
Cannot be ruled out
Nausea (gastric ulcer [GU])
Weight loss(GU)
Use of NSAIDS
Melena, blood streaked stools
Disease Rule In Rule Out
Gastric Carcinoma
Throbbing epigastric pain
Cannot be ruled out
Loss of appetite
Nausea
Weight loss
Melena, Blood streaked stools
Differential Diagnosis
Disease Rule In Rule Out
Nonulcer dyspepsia (NUD)/functional dyspepsia
Throbbing epigastric pain
Cannot be ruled outNo
reflux/regurgitation
Gastroesophageal Reflux Disease
Throbbing epigastric pain
No reported heartburn, regurgitation
Differential Diagnosis
Differential DiagnosisDisease Rule In Rule Out
Hepatobiliary Disease
Icteric scleraeNo UTZ findings related to the biliary tree
Multiple hepatic massesWeight loss
Melena No ascites
Hepatocellular Carcinoma
Multiple hepatic masses Normal AFP
Weight lossLoss of appetiteIcteric slera
Differential DiagnosisDisease Rule In Rule Out
Metastatic Malignancy
Multiple masses in the liver more indicative of metastasis than primary malignancy Cannot be ruled
outWeight lossSuspicion of para-aortic node enlargement on UTZ
UTI
Left lower quadrant pain radiating to the back
Cannot be ruled out
history of recurrent UTI, with previous treatment with antibioticsNocturia
AssessmentO Peptic Ulcer Disease
O t/c Malignancy with liver metastasisO t/c Urinary Tract Infection
(uncomplicated cystitis)O Other: Obesity grade 2
Clinical Pathway of Uninvestigated Dyspepsia
Patient present with recurrent epigastric pain and/or post prandial
fullness for > 2 weeksDo biopsychosocial history and
complete PEBurning
sensation radiating upward?
YesManage as
GERD
Regular NSAID use
Yes Manage as NSAID
induced Gastritis
No
No
No
Consider organic
pathology?
Uninvestigated
dyspepsiaRefer to a specialist
for possible EGD
NoYes Manage
organic pathology
No
Determine presence of
alarm feature Dyspepsia w/o alarm
symptoms
Yes
No
Empiric therapy for 2 weeks 1st line - PPIAlternative: H2RA, prokinetics, antacids
Lifestyle advice and psychosocial interventionFollow-up after 2 weeks
Symptoms resolved?
No
Yes
Continue PPI OR increase dose OR add
pro kinetics for 4 weeks
Lifestyle advice and
psychosocial intervention
Follow-up after 4 weeks
No further treatment
Symptoms resolved?
No further treatment
Yes
NoH. Pylori
test feasible?
NoEmpiric
EradicationSymptoms resolved?
H. Pylori test (+)?
Yes
NoYes
Eradication Treatment
PPI (increased dose) +
prokinetics for 4 weeks
Follow-up after 4 weeks
NoYesRefer to a specialist
for possible EGDNo further treatment
PlanO Diagnostics
O PUD: Referral to Gastrointestinal Clinic for Endoscopy, culture gastric contents for H.pylori, tissue biopsy of ulcer/s (if present)
O Abdominal CT-Scan with contrastO Labs:
O CBC, Platelet, Pt/PttO FBSO BUN, CreatinineO LFT, BilirubinO Urinalysis, Urine culture
PlanO Therapeutic
O PharmacologicalO Continue Omeprazole 20 mg OD before
breakfast O Tramadol HCl 50mg every 4 hours for the pain
O Non-PharmacologicalO Stop self-medication with Mefenamic Acid (NSAID
use)O Avoid intake of alcoholic beverages, coffee, sour
and spicy foodO Avoid stressO Do not skip meals
PlanO For Obesity:O Labs: Lipid profile
O -low cholesterol dietO Regular exerciseO Reduced intake of salty food and
sweets
PlanO Follow up after 10 days for analysis
of imaging results and evaluation of response to Omeprazole.