Case Write Up Surgery

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SURGERY 2

nd

_{CASE REPORT}

NAME : SHARVINDAN A/L SUBRAMANIAM

IC NUMBER : 900309-05-5063

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PATIENT IDENTIFICATION

NAME : Gopalakrishnan s/o Venkateswaran AGE: 56 years old

SEX: Male

ETHNIC GROUP: Indian ADDRESS: Sg.Buloh

MARRITAL STATUS: Married with 3 children OCCUPATION: School teacher

DATE OF ADMITTION: 15/12/2012 DATE OF CLERKING : 17/12/2012

CHIEF COMPLAINT

Patient came to Hospital Sungai Buloh on 15th_{of December 2012 with a}

complaint of passing of dark coloured stool and per rectal bleeding for the past one day associated with nausea.

HISTORY OF PRESENT ILLNESS

Mr Gopalakrishnan experienced bleeding in the morning when he went to the toilet at about 9am in the morning. He woke up at 8am in the morning and did gardening in his garden at home. While gardening, he suddenly felt nauseated and tired, thus, he went and took a rest in the house. He then had the sensation of passing motion and went to the toilet. When passing motion, he noted a large amount of blood came out together with the faeces and the toilet bowl was filled with fresh blood. This was the first episode for him. The blood was bright red in colour and there were no blood clots. There were no mucous. The stool was dark in colour. The stool was normal in amount and there was no associated abdominal pain. The patient told that the blood was quite a lot but he was unable to

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quantify the exact amount. He then felt dizzy and almost fainted. He could not

wake up by himself after that incident.

His wife cleaned him and he was brought to the hospital by an ambulance to the Emergency Department. In Emergency Department, his vital signs were monitored and 1 pint of blood was transfused. Besides that, x-ray and endoscopy was also done.

He normally goes to the toilet once daily, in the morning. There were no changes in his bowel habits. He did not notice the colour of his stool before. He had no urinary system symptoms. He had no vomiting. He had no loss of weight or loss of appetite.

He does not exercise. He described his is diet low in oil and he eats rice in the morning but does not eat anything at night.

ACCOMPANYING SYMPTOMS

He felt nauseated before passing motion. He experienced dizziness and syncopal attack immediately after the bleeding. He also had

palpitation after the bleeding. He didn’t experienced vomiting. He had no fever. He had no hematemesis or hematuria.

PAST MEDICAL AND SURGICAL HISTORY

He was diagnosed with hypertension 8 years back and is under medication. He also has diabetes for the past 8 years. Initially he was taking oral hypoglycemic drug, now he is taking insulin for the past 4 years. His follow up is in Sungai Buloh Hospital. He has not done blood transfusion before.

ALLERGIES AND DRUG HISTORY

He has no allergy to any medication or food. He is taking anti-hypertensive and insulin. Besides that, he is also taking aspirin for the

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past five years. He takes quarter tablet every morning and he could not remember the dose. He last took it one day before the bleeding.

FAMILY HISTORY

The patient does not know if the parent had any medical illness. There is no history of similar problem or malignancy in his family. He has five siblings and he is the eldest. One of his brothers has hypertension.

SOCIAL HISTORY

Mr Gopalakrishnan is married with 3 children. He works as a school teacher in Sekinchan. He stays in a terrace house nearby with good facilities. There is good supply of electricity and water. He told he is comfortable with his living condition and it is clean.

REVIEW OF SYSTEM

a) General review : He was not in pain and was lying comfortably. b) Respiratory system : He had no shortness of breath, flu or cough. c) Cardiovascular system : He had no chest pain or difficulty in

breathing.

d) Musculoskeletal system : He had no joint pain or difficulty in walking.

e) Genitourinary system : He had no difficulty, pain or noticed blood while urinating.

f) Gastrointestinal system : He had no difficulty in swallowing. No diarrhea or mucus noted by patient in his stool. However there was large amount of blood together with the dark stool. There were on associated abdominal pain.

g) Neurological system : Patient was not feeling dizzy,not under depression or anxiety.

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General Examination

Mr Gopalakrishnan is a well built male and was lying down in a supine position on the bed with a pillow on his head. He was not in pain or discomfort.He was moderately hydrated. His weight was 97kg, height was 168cm and BMI was 34.4 which suggests that he is obese. He was conscious during the examination and aware of the time and place he was at that time.

Upon vital signs, his temperature was recorded and it was 36.8º C, thus he was afrebile. His blood pressure was recorded 139/72 mmHg and the pulse rate was 80 beats per minute. His respiratory rate was 22 beats per minute. Examination of the hands revealed cold hands, there was pallor, no clubbing, no cyanosis and no tar-stained nails. There was also no palmar erythema on the hands. The capillary refill time was less than 2 seconds.

The face appears normal and it’s symmetrical. There was no pallor on both right and left conjunctiva and no jaundice on the sclera of the eye. There was no any scar on the face. Besides that there is no cyanosis, swelling, ulceration or dehydration seen inside the mouth, lips and tongue. Examination of the neck revealed no enlargement of the thyroid gland and no palpable lymph nodes within the cervical region. There was no pitting edema of lower limbs up to the level of ankle.

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On inspection, the abdomen was distended. There was no scar or surgical marks on the abdomen. There was no presence of visible veins. The hair distribution was normal. The umbilicus was inverted and centrally placed. The abdomen moves symmetrically with respiration.

On light palpation of the abdomen, there was no tenderness at any region of the abdomen. There was no guarding at any part of the abdomen. There was no rebound tenderness on the abdomen.

Murphy’s sign was negative indicating there was no gall bladder involvement. There was no Grey Turner’s sign in the flank or Cullen’s sign in the umbilicus seen. There were also no rebound tenderness and Rovsing’s sign was negative.

Upon deep palpation on the abdomen, there was no pain. During palpation of the solid organs, the liver appears normal, there was no enlargement and the liver span was 11cm. There was no enlargement of the spleen and it is not palpable. The kidneys were normal, no enlargement and its impalpable.

On percussion of the abdomen, it was resonance. There was no presence of shifting dullness and no fluid thrill present. There was no ascites detected on percussion.

On auscultation, there were low-pitched gurgling sound heard and was 4 sounds per minute. There were no abnormal bowel sounds heard.

DIAGNOSIS & DIFFERENTIAL DIAG

NOSIS

DIFFERENTIAL DIAGNOSIS

1) Symptomatic anemia secondary to upper gastrointestinal bleeding,aspirin induced. 2) Lower gastrointestinal bleeding

3) Hemorrhoids

4) Peptic Ulcer Disease 5) Systemic bleeding disorder

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1) The stool was dark,tarry indicating bleeding was from upper gastrointestinal tract. Patient also presented with syncopal attack immediately after the bleeding resulting from high amount of blood loss.There had been occult blood in the stool which was unnoticed.

2) Rectal examination was done and there was no mass noted.Patient did not feel itchiness anywhere regarding perianal area.This excludes hemorrhoids.

3) Patient had no past history of gastritis before and no abdominal pain felt. Food intake did not caused vomiting or pain in the abdomen.Thus,peptic ulcer disease can be excluded.

4) Patient had no history of bleeding disorder such as hemophilia,excessive

anticoagulation or thrombocytopenia. Blood coagulation profile of the patient was normal.Patient not suffering from any blood disorder.

5) Patient felt naused prior to the rectal bleeding.Stool was dark coloured and mucous was absent. He also had syncopal attack immediately after the bleeding. This indicates that there was internal bleeding from the upper gastrointestinal tract.Patient was also under aspirin for the past 5 years.

DIAGNOSIS : Symptomatic anemia secondary to upper gastrointestinal bleeding, aspirin induced.

INVESTIGATION

IMAGING

A ) ULTRASOUND ABDOMEN

The liver was normal in size and echotexture. There was no focal lesion. Intrahepatic ducts and common bile duct were not dilated. Gallbladder was well distended and there was no calculi or polyps within it. Spleen was normal,no enlargement detected.Kidneys were normal in size and echogenicity,Bipolar lengthS and cortical thickness-right kidney 9.1/0.7cm and left kidney 10.2/1.0cm. There was no calculi or hydronephrosis bilaterally.Urinary bladder appears grossly normal. Prostate was not enlarged. The appendix wall appeared normal. Pancreas appeared normal.

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LABORATORY

Full Blood Count (FBC)

Result Normal

range

Impression

White Blood Cell 21.9 x 10^9/L 4.00 - 11.00 Normal Red Blood Cell 5.10 x 10^12/L 4.50 - 5.50 Normal Haemoglobin 15.8 g/dL 13.0- 17.0 Normal Haematocrit 50.3 % 40.0 - 54.0 Normal Mean Cell Volume 88.5 fl 83.0- 101.0 Normal Mean Cell Haemoglobin 29.4 pg 24.0- 33.0 Normal Mean Cell Haemoglobin

Concentration

33.2 g/dL 31.0- 37.0 Normal Red Cell Distribution

Width 13.9 % 11.5- 14.5 Normal Platelet 128 x10^9/L 110-450 Normal Percentage Of Neutrophil 75.4 % 40.0-80.0 Normal Percentage of Lymphocyte 22.2 % 20.0- 40.0 Normal Percentage Of Monocyte 7.7 % 2.0- 10.0 Normal Percentage Of Eosinophil 1.0 % 1.0- 6.0 Normal Percentage of Basophil 0.3 % 0.0- 2.0 Normal Absolute Neutrophil 6.02 x 10^9/L 1.90- 8.00 Normal Absolute Lymphocyte 1.74 x 10^9/L 0.90- 5.20 Normal Absolute Monocyte 0.95 x 10^9/L 0.16 -1.00 Normal Absolute Eosinophil 0.40 x 10^9/L 0.00- 0.80 Normal Absolute Basophil 0.03 x 10^9/L 0.00-0.20 Normal

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Cardiac Enzymes

range

Impression

Aspartate Transaminase 28 U/L 5-34 normal Lactate Dehydrogenase 148 U/L 125-220 normal Creatine Kinase 34 U/L 30-200 normal

Lipid Profile

range

Impression

Triglycerides 0.34 mmol/L 0.00- 1.70 normal LDL Cholesterol 0.88 mmol/L 0.00- 1.95 normal HDL Cholesterol 0.34 mmol/L 0.00- 1.03 normal Cholesterol 4.93 mmol/L 0.00- 5.20 normal

Renal Profiles

range

Impression

Urea 13.3 mmol/L 3.2 - 7.4 Abnormal Sodium 136 mmol/L 136- 145 normal Potassium 4.70 mmol/L 3.50- 5.10 Normal Chloride 100.0 mmol/L 98.0- 107.0 Normal Creatinine 165.5 umol/L 64.0- 111.0 Abnormal

Liver Function Tests (LFT)

Result Normal range Impression

Protein, Total 88.0 g/L 64.0 - 83.0 Abnormal

Globulin 48 g/L 19-33 Abnormal

Albumin/Globulin Ratio 0.83 1.2 - 1.5 Normal Bilirubin, Total 42.9 umol/L 3.4 - 20.5 Abnormal Alanine

Transaminase(SGPT)

35 IU/L 10–50 IU/L Normal

Albumin 40 g/L 35-50 Abnormal

Alkaline Phosphatase 83 U/L 40-150 Abnormal

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Phosphate Inorganic 0.69 mmol/L 0.74 - 1.52 Abnormal

Bilirubin Total and Direct

range

Impression

Bilirubin, Direct 7.1 umol/L 0.0- 8.6 Normal Billirubin, Indirect 26.6 umol/L 0.2-0.7 mg/dL Normal Bilirubin, Total 7.2 umol/L 3.4- 20.5 Normal

MEDICATIONS

i)Esomeprazole 40 mg tablet twice a day for 42 days ii) Prazocin (5g)

iii) Perindopril (4mg)

SUMMARY

Mr Gopalakrishnan came to Hospital Sungai Buloh on 15th_{of November}

2012 with a complaint of passing of dark coloured stool and per rectal bleeding for the past one day associated with nausea. He had

hypertension and diabetes. He was under aspirin for the past 5 years. On physical examination, there was no significant finding. There were several investigations carried out such as full blood count, lipid profile, renal

profile, CT scan, abdominal ultrasound, electrocardiogram, colonoscopy and liver function test.

Discussion

Gastrointestinal bleeding

Gastrointestinal (GI) bleeding refers to any bleeding that starts in the gastrointestinal tract. Bleeding may come from any site along the GI tract, but is often divided into:

 Upper GI bleeding: The upper GI tract includes the esophagus (the tube from the mouth to the stomach), stomach, and first part of the small intestine.

 Lower GI bleeding: The lower GI tract includes much of the small intestine, large intestine or bowels, rectum, and anus.

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Considerations

The amount of GI bleeding may be so small that it can only be detected on a lab test such as the fecal occult blood test. Other signs of GI bleeding include:

 Dark, tarry stools

 Larger amounts of blood passed from the rectum

 Small amounts of blood in the toilet bowl, on toilet paper, or in streaks on stool (feces)

 Vomiting blood

Massive bleeding from the GI tract can be dangerous. However, even very small amounts of bleeding that occur over a long period of time can lead to problems such as anemia or low blood counts.

Once a bleeding site is found, many therapies are available to stop the bleeding or treat the cause.

Causes

GI bleeding may be due to conditions that are not serious, including:

 Anal fissure

 Hemorrhoids

However, GI bleeding may also be a sign of more serious diseases and conditions, such as the following cancers of the GI tract:

 Cancer of the colon

 Cancer of the small intestine

 Cancer of the stomach

 Intestinal polyps (a pre-cancerous condition) Other possible causes of GI bleeding include:

 Abnormal blood vessels in the lining of the intestines (also called angiodysplasias)

 Bleeding diverticulum, or diverticulosis

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 Esophageal varices

 Esophagitis

 Gastric (stomach) ulcer

 Intussusception (bowel telescoped on itself)

 Mallory-Weiss tear

 Meckel's diverticulum

 Radiation injury to the bowel

Tests that may be done to find the source of the bleeding include:  Abdominal CT scan

 Abdominal MRI scan

 Abdominal X-ray

 Angiography

 Bleeding scan (tagged red blood cell scan)

 Blood clotting tests

 Capsule endoscopy (camera pill that is swallowed to look at the small intestine)

 Colonoscopy

 Complete blood count (CBC), clotting tests, platelet count, and other laboratory tests

 Enteroscopy

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