PBL example scenario

Trigger text

A persistent pain

Image: 79-year-old woman in her home by the phone – looking uncomfortable.

You are an SHO in A&E at the DRI. Nancy Allen, aged 79, has been referred by her GP for tests.

Over the last 2 days she has just not been feeling right and has had a persistent burning pain in her stomach. She has had the pain several times before but this time her antacid tablets haven’t helped at all. She has also noticed soft black stools. The pain had continued this morning and Nancy felt sick enough to vomit. Worried, she rang her friend and cancelled her lift to the Senior Citizens Club, and then went to see her GP.

Patient data

Presenting Problem

Mrs Nancy Allen is a 79-year-old pensioner who has been sent to the Emergency Dept that morning by her general practitioner because of upper abdominal pain and black stools over the last 2 days.

History of Present Illness

  • An epigastric burning sensation present for the last 2 days
  • Her pain is moderately severe but non radiating – relieved a little by eating and by an antacid (Gaviscon)
  • No history of weight loss but some vomiting occurs with the pain, this has occurred occassionally in the past
  • Bowel motions were soft and black over last 2 days
  • Has felt lethargic and weak
  • Long history of dyspepsia with periodic epigastric pain over last 2 years (three episodes of pain over last 12 months, each lasting about 2 or 3 weeks)
  • Takes over the counter ranitidine tablets for a week when pain occurs
  • Developed low back pain 3 weeks ago with X-rayof lumbar spine showing moderate degenerative changes
  • Began taking diclofenac, prescribed for her husband and left in the bathroom cupboard since his death

Past Medical History

  • Barium meal many years ago showed a scarred stomach
  • Has osteoarthritis, particularly affecting the hips
  • Moderate hypertension for many years controlled with felodipine (slow release tablets)
  • Moderate chronic airflow limitation related to lifelong cigarette smoking
  • Cholecystectomy 10 years ago for gallstones following episodes of biliary colic
  • Caesarean section for birth of second child 50 years ago
  • Chest X-ray three years ago showed no abnormality

Family History

  • Father had stomach ulcers and died of ischaemic heart disease aged 72

Personal and Social History

  • Widowed 2 years ago and lives alone in own home with some support from neighbours
  • Both children married and living in Plymouth
  • Main social contact with senior citizens club and local church
  • Largely independent in daily living but is considering meals on wheels to avoid strain of shopping
  • Drinks 4 or 5 units of alcohol per day as sherry before the evening meal
  • No history of known drug allergies
  • Has stopped smoking for 5 years but still gets breathless climbing stairs.
  • Current medications
  • o Felodipine slow release (10 mg daily)
  • o Diclofenac 50 mg twice daily for 3/52
  • o Ranitidine 150 mg periodically
  • Histopathology (see full report) – chronic active gastritis with numerous H. pylori organisms. Diagnostic Decision/Mechanism
  • H. pylori – associated peptic ulcer + improperly treated + exposure to risk factors (intake of NSAIDs) >>> inhibition of the protective mechanisms in the mucosa >>> bleeding from the ulcer as a complication

Progress management

  • Transfused 2 units of packed cells
  • Diclofenac ceased and omeprazole 20 mg daily begun
  • No signs of rebleeding
  • Repeat haemoglobin 2 days later was 11.8 g/dL (NR 12.0-16.0)
  • Prescription for one week triple therapy (omeprazole, amoxycillin, clarithromycin) with emphasis on the importance of compliance and possible side effects.
  • Continuation of omeprazole for 7 weeks after triple therapy completed

Outcome

  • Discharged after 4 days and asked to ring if side effects or further bleeding occurred
  • At an outpatient visit one week later reported no further epigastric pain

Investigations and management after eight weeks

  • Endoscopy showed reduced (0.4 cm) gastric ulcer and no signs of recent haemorrhage
  • Biopsies from ulcer edge were negative for malignancy
  • Multiple gastric antrum and corpus biopsies negative for H. pylori
  • Omeprazole continued for a further 4 weeks

Investigations and management after 12 weeks

  • Endoscopy showed ulcer completely healed and biopsies from scar negative for malignancy
  • Omeprazole was ceased
  • Advised to avoid non-steroidal anti inflammatory drugs and to present promptly if dyspeptic symptoms recurred
  • GP helped her to go through medications and discard any that were her husband’s or are not appropriate
  • She was referred to a physiotherapist and prescribed paracetamol, but this failed to relieve her back pain
  • Switched to ibuprofen (200 mg qid) plus misoprostol (200 p g qid)
  • Misoprostol induced diarrhoea and had to be ceased
  • Switched to a Cox-2 specific non-steroidal anti-inflammatory drug which was well tolerated until the pain settled, and then it was ceased.
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