Admission date : 19/4/49

Attending date : 19/4/49

95
( )
CC : 8 .
PI
: 8

3




2

PH : underlying HT, DM, IHD 10

admit
hypoglycemia

- ASA 1x1 p.c.
- Simvastatin
- Isordil (10) 1x3
- Aldactone (Spironolactone)
- Minidiab (Glipizide) (500) 1x1
- Digoxin
- Norvasc (Amlodipine) (10) 1x1 p.c.- Dextrometrophan
CA colon 11
Colectomy
abdominal hernia PU
5 gastroscope 2

FH :
SH : 60 1

Physical examination
General appearance : An elderly woman, look weak and thin, lying quietly on the
bed, good consciousness and well co-operation
Vital signs
: BT 37.2oC, BP 146/70 mmHg, PR 92 /min, RR 22 /min
HEENT
: mild pale conjunctivae, no jaundice
dry lip and tongue
pharynx and tonsil not injected
cervical and supraclavicular lymphnode impalpable
Heart
: no active precordium,
PMI at 5th intercostals space 1 c.m. Lt. to midclavicular line
no heaving, no thrill,
normal S1S2, no murmurs
Lung
: barrel shape appearance, redness spots on chest wall
equal lung expansion,
trachea in midline,
tympanic on percussion both lungs,
coarse crepitation both lower lungs
Abdomen
: obese abdomen, soft, not tender,
abdominal hernia bulging around umbilicus ~ 7c.m.,
liver and spleen impalpable,
active bowel sound,
CVA not tender, no spider nevi
Extremities
: no pitting edema, no petechiae, no hemorrhage,
no clubbing finger, poor skin turgor, no palmar erythema

CBC : Hb 6.5 g/dl, Hct 19.9%, WBC 13,900 cell/mm3, platelet 190,000, PMN 92%,
Lymphocyte 5.9%, Monocyte 1.8%, Eosiophil 0.2%, Basophil 10.1%, PT 11.8s, aPTT 20s, INR
1.07
Blood smear examination : normochromic normocytic
UA : Clear, yellow, specific gravity 1.015, pH 6.5, albumin 1+, glucose 3+, RBC 0-1
/hpf, WBC 0-1 /hpf, squamous epithelial cell 0-1 /hpf
Stool exam : soft, occult blood positive, parasite negative

Blood chemistry : blood sugar 192 g/dl, BUN 12.3 mg/dl, Cr 1.4 mg/dl, Na 139 mEq/l,
K 5.6 mEq/l, HCO3 18.1 mEq/l, Cl 115 mEq/l, Ca 8.7 mEq/l, PO4 3.8 mEq/l
LFT : Cholesterol 123 mg/dl, Total protein 4.4 g/dl, Albumin 2.7 g/dl, globulin 1.7 g/dl,
TB 0.5 mg/dl, DB 0.1 mg/dl, ALT 9 U/L, AST 8 U/L, ALP 38 U/L
EKG : PR = 85 /min, normal sinus rhythm, normal axis, no chamber enlargement, no
ischemic pattern
Problem list
1. Upper GI bleeding and anemia
2. Hypertension (HT)
3. Diabetes mellitus (DM)
4. Ischemic heart disease (IHD)
Discussion
1. Upper GI bleeding and anemia
S =
3 2
underlying HT, DM, ischemic
heart disease (IHD) PU 2
prophylaxis Ischemic heart disease Aspirin (ASA)
grain I p.c.
O = mild pale conjunctivae, no jaundice, dry lip and tongue, no clubbing finger,
no petechiae or hemorrhage, poor skin turgor Vital signs BT 37.2oC, BP
146/70 mmHg, PR 92 /min, RR 22 /min

CBC : Hb 6.5 g/dl, Hct 19.9%, WBC 13,900 cell/mm3, platelet 190,000, PMN 92%,
Lymphocyte 5.9%, Monocyte 1.8%, Eosiophil 0.2%, Basophil 10.1%, PT 11.8s, PTT 20s, INR
1.07
Blood smear examination : normochromic normocytic
UA : Clear, yellow, specific gravity 1.015, pH 6.5, albumin 1+, glucose 3+, RBC 0-1
/hpf, WBC 0-1 /hpf, squamous epithelial cell 0-1 /hpf
Stool exam : soft, occult blood positive, parasite negative
A =
(hematemesis)


hemoptysis


Stool
occulted blood positive

(Upper GI bleeding)
Upper GI bleeding
sign dehydration mild pale, poor skin
turgor blood pressure 146/70 mmHg
underlying Hypertension
(
)
CBC Hb Hct

Upper GI bleeding
(Gastritis) (Peptic ulcer)
esophageal varices ( cirrhosis portal hypertension)
Hemostasis platelet
coagulation system peptic ulcer
2 Ischemic
heart disease Aspirin (ASA) liver and spleen
impalpable, no spider nevi, no clubbing finger, no pitting edema, no petechiae or hemorrhage,
no palmar erythema Liver function test liver enzyme
1. aspirin
platelet aggregation
bleeding 2. Peptic ulcer
precipitate aspirin attack
esophageal varice cirrhosis
sign cirrhosis palmar erythema, spider nevi,
clubbing finger petechiae, hemorrhage

 CBC platelet PT, aPTT

hemostasis disorder
anemia CBC
Hb Hct Acute anemia
Acute blood loss

hemolytic anemia blood smear examination
microspherocyte,
polychromasia NRC
defect

Hb Hct Lab CBC

P = initial plan upper
GI bleeding (PRC) volume

Omeprazole proton pump inhibitor

Bleeding
NG (Nasogastric tube)
Upper GI bleeding
active

endoscope
2. Hypertension (HT)
S = underlying Hypertension 10 (
)

OPD card 160/85
mmHg

Norvasc (Amlodipine)
(10) 1x1 p.c ( )
O = blood pressure 146/70 mmHg no pitting edema

UA : Clear, yellow, specific gravity 1.015, pH 6.5, albumin 1+, glucose 3+, RBC 0-1
/hpf, WBC 0-1 /hpf, squamous epithelial cell 0-1 /hpf
Blood chemistry : blood sugar 192 g/dl, BUN 12.3 mg/dl, Cr 1.9 mg/dl, Na 139 mEq/l,
K 5.6 mEq/l, HCO3 18.1 mEq/l, Cl 115 mEq/l, Ca 8.7 mEq/l, PO4 3.8 mEq/l
A = Hypertension primary
(essential) hypertension

Hypertension (secondary hypertension)
renal disease acute chronic renal
failure blood chemistry BUN Cr
hypertension

phaeochromocytoma hyperthyroidism
steroid pitting edema
Cushings syndrome hyperaldosteronism
underlying
hypertension risk DM complication
cardiovascular Atherosclerosis
hypertension
P = Amlodipine
calcium channel blocker active
Upper GI bleeding


behavioral modification


3. Diabetes mellitus (DM)
S = DM 10 (
)

Minidiab (Glipizide) (500) 1x1

 110-140 mg/dL

O = opthalmoscope
(cataract) insulin
19 2549 : 6.00 . 316 mg/dL (RI 8U), 11.00 . 319 mg/dL (RI 12U),
16.00 . 238 mg/dL (RI 12U), 22.00 . 81 mg/dL
20 2549 : 6.00 . 343 mg/dL (RI 14U), 11.00 . 398 mg/dL (RI 14U),
16.00 . 289 mg/dL (RI 14U), 22.00 . 66 mg/dL

UA : Clear, yellow, specific gravity 1.015, pH 6.5, albumin 1+, glucose 3+, RBC 0-1
/hpf, WBC 0-1 / hpf, squamous epithelial cell 0-1 / hpf
Blood chemistry : blood sugar 192 g/dl, BUN 12.3 mg/dl, Cr 1.9 mg/dl, Na 139 mEq/l,
K 5.6 mEq/l, HCO3 18.1 mEq/l, Cl 115 mEq/l, Ca 8.7 mEq/l, PO4 3.8 mEq/l
A = Diabetes mellitus type 2
general appearance
DM type 2 type 1
type 1 (
500 mg/dL ) diabetic ketoacidosis

Minidiab (Glipizide) sulfonylurea
insulin Beta cell
complication DM Diabetes
nephropathy Blood chemistry Plasma Creatinine
Complication macrovascular
hypertension ischemic heart disease
DM risk atherosclerosis complication
diabetes neuropathy diabetes retinopathy


P = DM stress Upper GI
bleeding active stable
Regular insulin multiple s.c.
stress oral hypoglycemic
drug

 diabetic retinopathy urine 24 h.

monitor complication diabetic
nephropathy
4. Ischemic heart disease (IHD)
S = IHD 10 (
)

isordil prophylaxis myocardial infraction aspirin
O = S3, S4 gallop (EKG)
PR = 85 /min, normal sinus rhythm, normal axis, no chamber enlargement, no ischemic
pattern
A = Chronic stable angina
typical chest pain

reverse
isordil organic nitrate
preload prophylaxis MI Aspirin
(EKG)
ischemic pattern Chronic stable angina
progress unstable angina myocardial
infraction
P = prophylaxis chronic stable angina

aspirin upper GI bleeding
monitor
bleeding