DAVAO MEDICAL SCHOOL FOUNDATION, INC.

– COLLEGE OF MEDICINE
Department of Internal Medicine

Name: MEEVIE LOVE D. TOLEDO

Batch/Sec on: NMD 4 - GROUP 5 Date: NOVEMER 11, 2021

DAY 4 ACTIVITY

Instruc ons:
● Use Harrison’s Principles of Internal Medicine 20th edi on, Bate’s Guide to Physical Examina on and History Taking, or Clinical Prac ce Guidelines as your reference in answering this case. You may also
use the o cial textbooks used by other departments.
● Indicate the name of the book, chapter and page number in the reference column. Failure to write the reference will incur deduc on from the total grade.
Case:

Interpret the following diagnos c test results

Is this test important? Why? Discuss the pathophysiology behind such result (high/low, Reference
Diagnos c test Results Normal Value Interpreta on
posi ve/nega ve result). (Source, Page No.)
Henry’s Clinical Diagnosis and
Yes, this test is important as it assess the degree of bleeding of the pa ent. Hemoglobin (Hb), Management by Laboratory
the main component of the red blood cell (RBC), is a conjugated protein that serves as the Method 22nd edi on, Appendix
vehicle for the transporta on of oxygen (O2) and carbon dioxide (CO2). Anemia is a decrease 5, page 1503; Chapter 30, pages
Hgb 8 g/dL 14–17.5 g/dL Low to below normal Hb concentra on, erythrocyte count, or hematocrit (Hct). It is a very 510-512
common condi on and is frequently a complica on of other diseases. As in the case of the
pa ent, there is persistent bleeding caused by the Pep c ulcer disease that caused the Harrison’s Principles of Internal
decrease in hemoglobin level. Medicine 20th edi on Chapter
93, page 685

PREPARED BY: M. PLATERO, RN, MD, FPCP 1

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
Henry’s Clinical Diagnosis and
Management by Laboratory
Method 22nd edi on, Appendix
Yes, this test is important as it assess the degree of bleeding of the pa ent. The hematocrit
5, page 1503; Chapter 30, pages
(Hct) of a sample of blood is the ra o of the volume of erythrocytes to that of the whole
Hematocrit 31% 41.5–50.4% Low 512-513
blood. As men oned, hematocrit decrease to below normal in cases of anemia and for the
pa ent in this case, it is because of the chronic blood loss caused by the Pep c ulcer disease.
Harrison’s Principles of Internal
Medicine 20th edi on Chapter
93, page 685
Henry’s Clinical Diagnosis and
Management by Laboratory
Yes, this test is important as it serves as an indica on of penetra ng ulcer is present. The
Method 22nd edi on, Appendix
serum amylase and lipase levels are widely used as screening tests for acute pancrea s in
5, page 1492
Amylase 100 U/L 30–220 U/L Normal the pa ent with acute abdominal pain or back pain. Values greater than three mes the
upper limit of normal (3× ULN) in combina on with epigastric pain strongly suggest the
Harrison’s Principles of Internal
diagnosis of acute pancrea s. For this pa ent, the serum amylase level is normal.
Medicine 20th edi on Chapter
340, page 2433
Yes, this test is important as it serves as an indica on of penetra ng ulcer is present. The
serum amylase and lipase levels are widely used as screening tests for acute pancrea s in Harrison’s Principles of Internal
Lipase 14 U/L 14–280 U/L Normal the pa ent with acute abdominal pain or back pain. Values greater than three mes the Medicine 20th edi on Chapter
upper limit of normal (3× ULN) in combina on with epigastric pain strongly suggest the 340, page 2433
diagnosis of acute pancrea s. For this pa ent, the serum lipase level is normal.
Endoscopic view of the duodenum
Harrison’s Principles of Internal
Medicine 20th edi on Chapter
317, page 2228
Yes, this test is important as itprovides the most sensi ve and speci c approach for
examining the upper GI tract. It permits direct visualiza on of the mucosa and facilitates
Forresy, KA. Endoscopy in
photographic documenta on of a mucosal defect and ssue biopsy to rule out malignancy
No ulcera on Forrest III gastrointes nal bleeding.
(GU) or H. pylori. It is par cularly helpful in iden fying lesions too small to detect by
Lancet; 1974
radiographic examina on, for evalua on of atypical radiographic abnormali es, or to
determine if an ulcer is a source of blood loss.
Laine L, et. al. ACG Prac ce
Guidelines on Management of
Ulcer Bleeding, ACG 2012
Rapid Urease Test

PREPARED BY: M. PLATERO, RN, MD, FPCP 2

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
Henry’s Clinical Diagnosis and
Management by Laboratory
Method 22nd edi on Chapter
Yes, this test is important as it provides informa on if H. pylori infec on co-exist with NSAID Chapter 22, page 316; Chapter
use as the cause of PUD. Rapid urease test is a rapid test for detec on of urease ac vity used 57, page 1103
in presump ve iden ca on of gastric biopsy specimens. Gastric biopsy is placed into urea-
Nega ve Posi ve
containing medium with color indicator (phenol red). If H. pylori is present, the urease Uotani, Takahiro, and David Y.
rapidly splits urea and resul ng shi in pH yields a color change in the medium, from yellow Graham. "Diagnosis of
to red/pink. In the case of the pa ent, H. pylori infec on is present. Helicobacter pylori using the
rapid urease test." Annals of
transla onal medicine 3.1
(2015).
Henry’s Clinical Diagnosis and
Management by Laboratory
Method 22nd edi on Chapter
Chapter 22, page 316; Chapter
57, page 1103
Endoscopy allows collec on of ssue for rapid urease tes ng to document the presence of H. pylori. As men oned earlier,
How is rapid urease test being done? Gastric biopsy is placed into urea-containing medium with color indicator (phenol red). If H. pylori is present, the urease rapidly
Uotani, Takahiro, and David Y.
splits urea and resul ng shi in pH yields a color change in the medium, from yellow to red/pink.
Graham. "Diagnosis of
Helicobacter pylori using the
rapid urease test." Annals of
transla onal medicine 3.1
(2015).

PREPARED BY: M. PLATERO, RN, MD, FPCP 3

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine

INTERPRET THE 12 LEADS ECG

Reference
Evaluate Answer (source, page
no.)
Rate: ● 125 bpm
Rhythm: ● Sinus
PR: ● 0.20 seconds
QRS: ● 0.08 seconds
Axis (give exact numerical
+ 82 degrees
value): ●
QT: ● QTc = 0.46 seconds
ECG reading: ● Sinus Tachycardia
Supraventricular
tachyarrhythmias originate from
Harrison’s
or are dependent on conduc on
Principles of
through the atrium or
What is supraventricular Internal
atrioventricular (AV) node to the
tachyarrhythmia/tachycardia Medicine
ventricles. Most produce narrow
(SVT)? 20th edi on
QRS-complex tachycardia (QRS
Chapter 241,
dura on <120 ms) characteris c
page 1733
of ventricular ac va on over the
Purkinje system.

PREPARED BY: M. PLATERO, RN, MD, FPCP 4

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
De ne physiologic sinus
tachycardia.
De ne pathologic SVT
Sinus tachycardia (>100 beats/ Harrison’s
min) typically occurs in response Principles of
to sympathe c s mula on and Internal
vagal withdrawal. It is Medicine
considered physiologic when it 20th edi on
is an appropriate response to Chapter 242,
exercise, stress, or illness page 1735
Pathologic SVT is sub-classi ed
in terms of mechanism as
reentrant arrhythmias Harrison’s
dependent on AV nodal Principles of
conduc on (e.g., AV reentry), Internal
large reentry circuits within the Medicine
atrial ssue alone (e.g., atrial 20th edi on
u er) or focal atrial Chapter 241,
tachycardias that can be due to page 1733
automa city or small reentry
circuits.

This ECG is a cause of Harrison’s

physiologic sinus tachycardia as Principles of
Internal
it occurs in response to the
Is this ECG a case of Medicine
bleeding secondary to pep c
physiologic sinus tachycardia 20th edi on
ulcer disease, wherein there is a
or pathologic SVT? Jus fy. Chapter 242,
need for the heart to pump page 1735;
more blood in order to increase Chapter 93,
oxygen delivery to ssues. page 685
SVT produces narrow QRS-
Harrison’s
complex tachycardia (QRS
Principles of
dura on <120 ms) characteris c
Internal
Di eren ate SVT from of ventricular ac va on over the
Medicine
ventricular tachycardia in Purkinje system, white VT
20th edi on
terms of pacing origin and originates from a stable focus or
Chapter 241,
QRS morphology? reentry circuit and presents as a
page 1733;
wide QRS tachycardia that has
Chapter 249,
the same QRS con gura on
page 1757
from beat to beat.

PREPARED BY: M. PLATERO, RN, MD, FPCP 5

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine

INTERPRET THE CHEST X-RAY

Evaluate Describe
Exposure? ● X-ray has sa sfactory penetra on.

Expansion ● There is sa sfactory inspiratory achievement.

AP or PA view? ● This a PA chest X-ray of an adult.

Airways ● The trachea is the midline.

Bones ● There is no abnormality of the imaged so ssues or skeleton; in par cular, there are no rib fractures.

Cardiac/Medias num/CT ● The heart is not enlarged and the cardiac and medias nal contours are normal.
ra o ● Cardiothoracic ra o is 0.45

● Both hemidiaphragms are clearly demarcated.

Diaphragm No free subdiaphragmaHc gas seen.
●
Costophrenic and ● The costophrenic and cardiophrenic angels are sharp with no evidence of pleural e usion.
cardiophrenic angles
Lung Fields ● The lungs are clear, with no masses, nodules, consolida on or collapse available.

Impression: Normal chest x-ray

Is this diagnos c test

Yes, this diagnos c test is necessary for this case as it is useful in detec ng free abdominal air
necessary for this case?
when perfora on (a complica on of PUD) is suspected.
Jus fy your answer.

PREPARED BY: M. PLATERO, RN, MD, FPCP 6

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
Complete working diagnosis: ● Duodenal Ulcer Forrest III secondary to Helicobacter pylori infec on and NSAID use; Anemia secondary to Chronic blood loss

What medicines will you give SPECIFIC FOR THIS PATIENT considering your history and physical examina on ndings, diagnos c test results, and working diagnosis?
Make a brief drug study. Answers in bullet format. Key words or points only.

Dosing, Route, Frequency & Reference

Drug Drug Classi ca on Mechanism of Ac on Contraindica ons Side E ects and what to monitor Common drug-drug interac ons
Dura on of use (Source, page no.)

Omeprazole Proton Pump Inhibitor It blocks the nal step in gastric acid secre on 20 mg BID PO for 14 days Concomitant use with nel navir. Hypomagnasaemia, nausea, vomi ng, Decrease plasma concentra ons of
by speci c inhibi on of adenosine cough nel navir and atazanavir.
triphosphatase (ATPase) enzyme system present Increased risk of
on the secretory surface of the gastric parietal Monitor: Serum Mg+ level hypomagnesaemia with diure cs. The Washington
cell. Both basal and s mulated acid are Manual of Medical
inhibited. Therapeu cs 36th
edi on (PDF
Clarithromycin Macrolide It selec vely binds to the 50S ribosomal subunit 500 mg BID PO for 14 days Hypersensi vity to clarithromycin Hepa c dysfunc on (e.g. increased May result in signi cant version) page 1873
of suscep ble bacteria and prevents the or any macrolide an bio cs. liver enzymes, hepatocellular and/or hypoglycaemia with oral
ac vated amino acids transloca on, resul ng in cholesta c hepa s with or without hypoglycaemics (e.g. sulfonylureas, Good and Gilman’s
inhibi on of intracellular protein synthesis. jaundice); exacerba on or new onset of repaglinide, nateglinide) and The Pharmacological
myasthenia gravis. insulin. Basis
of Therapeu cs.
Monitor: AST, ALT Chapter 49 pages
Metronidazole Nitroimidazole It Interacts with the microbial DNA to break its 500 mg TID PO for 14 days Hypersensi vity to metronidazole Severe neurological disturbances, Confusional state or acute 916-918
an microbials strand and helical structure leading to inhibi on and other nitroimidazoles. encephalopathy, convulsive seizures, psychosis with disul ram.
of protein synthesis, degrada on, and cell asep c meningi s, peripheral and op c May poten ate an coagulant Harrison’s Principles
death. neuropathy, paraesthesia; e ect of warfarin. of Internal Medicine
superinfec on 20th edi on Chapter
93, page 686;
Monitor: CBC with di eren als Chapter 317, page
2228-2238
Misoprostol Prostaglandin E1 It protects the GI mucosa by inhibi ng basal, 200 mcg QID PO for 14 days Pregnancy Diarrhoea, dyspepsia, atulence, Mg-containing antacids may
analogue s mulated and nocturnal acid secre on and by abdominal pain, nausea, vomi ng, aggravate misoprostol-induced
reducing the volume of gastric secre ons and rashes, dizziness, headache, increased diarrhoea.
increasing bicarbonate and mucus secre on. uterine contrac lity, abnormal vaginal
It also induces contrac ons of smooth muscle bleeding.
bres of the myometrium and relaxa on of the
cervix uteri. Monitor: if female, pregnancy test rst

PREPARED BY: M. PLATERO, RN, MD, FPCP 7

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Acetaminophen Analgesic Not fully understood
It penetrates the blood brain barrier -> blocks
COX3 in brain -> blocks the formatuon and
release of prostaglandins in the CNS -> Inhibits
the ac on of endogenous pyrogens on the heat-
regula on centers of the brain
Department of Internal Medicine
325mg Q4H as needed for joint
pain
• rash, nausea, and headache
Contraindica ons to the use of
acetaminophen include hypersensi vity
to acetaminophen, severe hepa c
impairment, or severe ac ve hepa c
disease
Substances that induce or regulate
hepa c cytochrome enzyme
CYP2E1 may alter the metabolism
of acetaminophen and increase its
hepatotoxic poten al.

Monitor: desired clinical e ects, such

as pain or fever relief.

Ferrous sulfate Dietary supplement Ferrous sulfate facilitates oxygen transport via
Hb. It is used as iron source as it replaces iron
found in Hb, myoglobin and other enzymes.
65 mg TID OD Gastrointes nal irrita on, nausea,
vomi ng, epigastric pain,
diarrhoea, cons pa on, blackening
of stool, tooth discoloura on,
abdominal discomfort
Monitor: Hb and haematocrit; RBC
count and indices, serum ferri n,
transferrin satura on, total iron-
binding capacity, serum iron
concentra on and erythrocyte
protoporphyrin concentra on.
May decrease the absorp on of
tetracyclines, uoroquinolones
(e.g. cipro oxacin, nor oxacin,
o oxacin), bisphosphonates,
levodopa, methyldopa,
penicillamine, entacapone and
levothyroxine.

Based on the data presented (HPI, PE, Diagnos c test results), formulate
addi onal medical orders for this pa ent especially a er knowing the Ra onale Reference
endoscopy result of this pa ent and other laboratory tests.
● Monitor vital signs ● To monitor the condi on of the pa ent Philippine Society of Gastroenterology 3rd
edi on (2000). H. pylori in Pep c Ulcer Disease
page 99
● Request for CBC with di eren als, Serum Crea nine, BUN, AST, ALT ● To monitor anemia, kidney func on, liver func on, and input The Washington Manual of Medical Therapeu cs
level, and Urinalysis. and output status. 36th edi on (PDF version) pages 1820 & 1821

Protocol for Diagnosis and Treatment of Pep c

Ulcer in Adults. American Interna onal Health
Alliance. page 3

Henry’s Clinical Diagnosis and Management by

Laboratory Method 22nd edi on Chapter 28,
page 449; Chapter 30, pages 510, 512 & 513

PREPARED BY: M. PLATERO, RN, MD, FPCP 8

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 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
● Triple therapy
o Omeprazole 20 mg BID PO for 14 days
o Clarithromycin 500 mg BID PO for 14 days
o Metronidazole 500 mg TID PO for 14 days
● Con rm eradica on 4 weeks a er treatment
Department of Internal Medicine
● For H. pylori eradica on
● To assess e ec vity of treatment
● To con rm eradica on of H. pylori
Philippine Society of Gastroenterology 3rd
edi on (2000). H. pylori in Pep c Ulcer Disease
page 99
Harrison’s Principles of Internal Medicine 20th
edi on Chapter 93, page 686; Chapter 317, page
2228-2238
Philippine Society of Gastroenterology 3rd
edi on (2000). H. pylori in Pep c Ulcer Disease
page 99

PREPARED BY: M. PLATERO, RN, MD, FPCP 9

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