Identifying Information

Name: Mr. GT
Age: 53 years old
Sex: Male
Chief Complaint: vomiting of bloody and mucoid material

History and Physical Examination

A. History of Present Illness

This is a case of Mr. GT, 53 year old male businessman, who sought consultation at the
outpatient department due to vomiting of bloody and mucoid material.
Two years prior to consultation, the patient was said to experience recurrent abdominal
pain every once or twice a month. The pain was said to be vague in characteristic and no
medications were done.
One year prior to consultation, the patient still experienced a recurrent and persistent
abdominal pain with a burning sensation located in the epigastric region but did not radiate. The
patient also experienced pain right after eating that would last 2-3 hours and resolved
spontaneously
Five months prior to consultation, the patient was said to experience recurrent
abdominal pain at 2 to 3 am in the morning and relieved by kremel S. Also because of this, he
began to experience trouble in sleeping. No fever during this time was noted.
One month prior to consultation, the patient still has abdominal pain and this time, he
already experiences vomiting. He took medications to relieve the pain but was not resolved.
One week prior to consultation, the patient was said to experience abdominal
bloatedness and said to vomit undigested foods.
Three days prior to consultation, he was then vomiting a large amount (1 cup) of foul-
smelling vomit, and experienced malaise, weakness.
On the day hours prior to his consultation, the patient vomited a bloody, mucoid material
and hence decided to seek consultation with the attending physician at the hospital at the
outpatient department.

B. Past Medical History

The patient is known to be hypertensive and maintains Amlodipine (5mg, once a day) for
almost 5 years. He is not diabetic and asthmatic. The patient did not have previous
hospitalizations before, no surgical operations, and has no known allergies.

C. Family History
 His father died 8 years ago at the age of 70 due to a heart attack. He was a known
hypertensive however maintenance medication were unrecalled due to poor compliance and
opted to herbal medication instead. The mother and his siblings are all generally healthy and in
good condition as claimed.

D. Personal and Social History

Patient is a 53 year old businessman with a live-in partner and 2 children. His eldest is
27 years old and and his youngest is a 19 year old college student. The patient is a smoker and
usually consumes 1-2 sticks of cigarettes per day for 10 years. He was an occasional alcoholic
drinker. Nutrition intake was fine.

Review of Systems

General: Weight loss of 7 pounds for the past 1 year was noted. Fatigue or weakness is noted
but no fever.

Skin: No rashes, no lumps, no changes in hair and nails, no jaundice

HEENT: Good vision, good hearing, no headaches but with dizziness when standing. No lumps,
no difficulty of swallowing. No neck pain, stiffness, lumps or swollen glands.

Respiratory: No cough, no wheezing or chills, no shortness of breath.

Cardiovascular: No chest pain but with occasional palpitations.

Gastrointestinal: Poor appetite with nausea and vomiting and presence of abdominal pain. No
constipation or change in bowel movement. No jaundice and diarrhea.

Genitourinary: No urine inconsistency, no hematuria, flank pain and no urine urgency.

Genitals: Denies any hernias, genital discharge lumps or rashes.

Musculoskeletal: No joint pain or swelling, no back pain, no muscle pain noted.

Hematologic: no history of anemia, easy bruising or bleeding.

Neurologic: No history of seizures, numbness but with presence of weakness.

 Physical Examination

General Survey:

Height: 172 cm

Weight: 57 kg

BMI : 19

Motor, posture, and activity: Patient is awake, conscious, coherent, and not in respiratory
distress but appears to be weak.

Vital Signs:

Temperature: 37 C

Respiration Rate: 21/min

Blood pressure: 110/70 mmHg

Pulse rate: 110

Skin: Skin warm, dry, with good turgor and no rashes. Hair normal texture and distribution. No
nail changes.

HEENT: Sunken eyeballs, pinkish conjunctiva with unecteric sclera, no flaring, but with dry lips
and oral mucosa.

Neck: Grossly non-swollen. No asymmetry. No decrease in ROM. No lymphadenopathy, goiter

or masses detected.

Respiratory: Round chest cavity. No increase of accessory muscles – no evidence of increased

work of breathing. No retractions. Lungs are clear to auscultation bilaterally. No stridor,
wheezes, crackles, or rubs. Good air movement.

CV: Dynamic precordium, no right ventricular heave, no thrills. Tachycardic but regular rhythm
at 5th intercostal space left midclavicular line.

Abdomen: distended abdomen, normoactive sound. Tenderness over epigastric area extending
to the right and left midline. No masses

DRE: tight sphincter tone, no mass palpated, hollow rectal vault, no mass palpated. No blood
noted
Extremities: no deformities, strong palpable pulses.