11

Case 11


History



A 56-year-old gentleman is admitted for severe epigastric pain, tarry stools and generalised malaise. He has a past history of ischaemic heart disease, gout and recent biliary pancreatitis which he underwent endoscopic retrograde cholangiopancreatography for stone removal. He is a non-drinker and takes a COX-2 inhibitor for his joint pain.


Physical examination


•Low-grade fever, pulse 100 bpm, BP 124/69mmHg, SaO2 97% on RA.


•Hydration is satisfactory.


•Examination of the hands reveals no clubbing and normal-appearing palmar creases.


•Head and neck examination is unremarkable.


•Cardiovascular: HS dual, no murmur.


•His chest is clear on auscultation.


•Abdominal examination reveals mild epigastric discomfort, with no definite mass.


•Per rectal examination: old melaena.


•No signs of oedema.


Investigations


•CBC:


–WBC 12.2 x 109/L;


–haemoglobin 10.4g/dL dropped to 8.5g/dL;


–platelets 259 x 109/L.


•CXR: grossly clear, with no free gas under the diaphragm.


•Urea normal.


•Amylase 310 IU/L.


•Liver and renal function tests are normal.


What is your differential diagnosis?


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Oct 23, 2019 | Posted by in GASTROENTEROLOGY | Comments Off on 11

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