PBL CASE2

TUTORIAL 1
PAGE 1
Mr. Wang, a 64-year-old male, presented with nausea and coffee ground emesis in your department. In the past 1 month, he suffered from recurrent epigastric pain accompanied with bloating, belching and anorexia.
1.
What the key symptoms were presented in this case?
2.
What are the possible etiologies and the associated pathogenesis of these symptoms.
3.
For the definite diagnosis, what more details should you ask the patient, such as any risk factors, characteristics of these symptoms and any accompanying symptoms?

TUTORIAL 1
PAGE 2
According to Mr. Wang’s complaint, he had been suffering from recurrent epigastric burning pain accompanied with bloating, belching and anorexia for 1 month, but without weight lose. After an episode of hematemesis (about 200 ml coffee ground emesis) accompanied with weakness and dizziness, he came to your department. The patient did not vomit vigorously before hematemesis. There was no history of alcohol abuse or intake of NSAIDs, nor experience of surgery or trauma. He also denied the history of acute or chronic viral hepatitis.
1.
According to the presentation ,what is the most possible diagnosis?
2.
What kinds of examination should you recommend to Mr. Wang?

TUTORIAL 1
PAGE 3
Physical examination: Temperature: 37.6
℃, Blood Pressure: 90/60mmHg.
The patient looks pale. There is no jaundice of his skin and sclerae. No signs of bleeding on his skin. Neither spider nevi nor liver palms are found. Superficial lymph nodes are not palpable. The heart rate is 96 per minute with regular rhythm, without any murmur. Chest auscultation: normal sounds, no rales. The abdomen is flat and soft; no dilated vein; no visible intestinal pattern and peristaltic wave. There is mild tenderness beneath the xiphoid process, without muscle guarding and rebound tenderness. There are no palpable liver, spleen or other masses. There is no shifting dullness. Bowel sounds are heard 8 per minute. There is no edema in the lower extremities.
1.
Could you find any clues from above information that might benefit for your diagnosis?
2.
Which following examinations should you order for the patient:
- Occult bleed test of vomitus or stool
- Blood routine test
- Liver function test
- Heptic virus
- Chest X ray
- Abdominal ultrasound
- emergency gastroscopy
3. What should you do before emergency gastroscopy?

TUTORIAL 2.
PAGE 1
Mr.Wang came back 3 hours later. The results are as follows:
1.
Occult bleed test of vomitus: ++++
2.
WBC 11.5*10
9
/L ； RBC350*10
12
/L ； Hb 80g/L ； PLT: 12*10
9
/L
3.
Liver function test: Normal
4.
Heptic virus: HbsAg (-)
5.
Abdominal ultrasound: Fatty liver; the gallbladder wall is slightly thickened; the spleen and pancreas have a normal shape and size.
6.
Emergency gastroscopy: Gastric angular ulcer; Chronic gastritis; Hp +
1.
What’s your final diagnosis according to the above information?
2.
How would you treat Mr. Whang?
3.
Would you order any more examinations for the patient?

TUTORIAL 2 .
PAGE 2.
You treat the patient with antacids (proton pump inhibitor), hemostasis, arrange v olume replacement with crystalloid and colloid, and manage the other supportive and symptomatic treatment.
1. What is the biochemical and pharmacological mechanism for the therapy?
2. How will you further therapy the patient after the bleeding stopped?

TUTORIAL 2
PAGE 3
After 5 hours treatment, the patient had two black stools (about 500ml totally) without vomiting. He felt tachycardia, dizziness and thirst.
1 、 What examinations should you manage for him now?
2 、 How to treatment him then?