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 masses

Weight loss

Melena No ascites

Hepatocellular Carcinoma

Multiple hepatic masses

Normal AFP

Weight loss

Loss of appetite

Icteric 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 loss

Suspicion 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 weeks

Do biopsychosocial history and complete PE

Burning sensation radiating upward?

YesManage as

GERD

Regular NSAID use

Yes Manage as NSAID

induced Gastritis

No

No

No

Consider organic

pathology?

Uninvestigated

dyspepsia

Refer to a specialist for possible EGD

No

Yes 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

No

H. Pylori test

feasible?No

Empiric Eradication

Symptoms 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.