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SEX: Male
ADDRESS: Sg.Buloh
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.
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 didnt
experienced vomiting. He had no fever. He had no hematemesis or hematuria.
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.
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 36.8 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 its 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.
ABDOMINAL EXAMINATION
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.
Murphys sign was negative indicating there was no gall bladder involvement. There
was no Grey Turners sign in the flank or Cullens sign in the umbilicus seen. There were also
no rebound tenderness and Rovsings 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 auscultation, there were low-pitched gurgling sound heard and was 4 sounds per
minute. There were no abnormal bowel sounds heard.
DIFFERENTIAL DIAGNOSIS
WORKING DIAGNOSIS
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.
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.
B) Colonoscopy
LABORATORY
Cardiac Enzymes
Lipid Profile
Result Normal 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
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.
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:
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
Hemorrhoids
However, GI bleeding may also be a sign of more serious diseases and conditions, such as the
following cancers of the GI tract:
Abnormal blood vessels in the lining of the intestines (also called angiodysplasias)
Esophageal varices
Esophagitis
Mallory-Weiss tear
Meckel's diverticulum
Tests that may be done to find the source of the bleeding include:
Abdominal CT scan
Abdominal X-ray
Angiography
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
Sigmoidoscopy