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45-Year-Old Male with Severe Abdominal Pain and Erosive Gastritis: Clinical Insights

A 45-year-old male presents with severe epigastric pain, relieved by food and antacids, accompanied by melena. He has a history of self-medication with omeprazole and has engaged in smoking and alcohol consumption. Physical examination reveals signs of distress with hypotensive and tachypneic responses. UGI endoscopy shows erosive gastritis, raising concern for perforation potentially due to peptic ulcer disease (PUD). Ongoing evaluation is critical to manage the patient’s condition and implement necessary interventions.

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45-Year-Old Male with Severe Abdominal Pain and Erosive Gastritis: Clinical Insights

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Presentation Transcript

  1. General Data • Age: 45 year old • Sex: male • Chief Complain: Severe Abdominal Pain

  2. History of Present Illness • Crampy, epigastric pain • Relieved by food intake or antacids • Melena • UGI endoscopy: Erosive Gastritis • Unrecalled medications 3 years PTA • Epigastric pain • Melena • Self‐medicated: Omeprazole 1 year PTA

  3. History of Present Illness A few hours PTA • Severe epigastric pain ADMISSION

  4. Past Medical History (-) HPN (-) DM Family History (-) Cancer Personal History • 10 pack‐years smoking • Drinks alcoholic beverage for 8 years

  5. Review of Systems (-) Weightloss (-) Dizziness (-) Chestpain

  6. Physical Examination • Conscious, coherent, in distress • BP= 140/90, PR= 105/min, RR=26/min ,T= 37.8 C • Warm moist skin, no active dermatoses • Pink palpebral conjunctivae, anictericsclerae • Heart and Lungs: regular rate and rhythm, clear breath sounds • Abdomen : flat, hypoactive bowel sounds, 􂈗 guarding and tenderness on all quadrants • DRE: brown stool on tactating finger

  7. Salient Features Pertinent Objective • PR= 105/min, RR=26/min • Abdomen : flat, hypoactive bowel sounds, (+) guarding and tenderness on all quadrants • DRE: brown stool on tactating finger Pertinent Subjective • 45 y/o • Crampy, epigastricpain, relieved by food intake or antacids • Melena • UGI endoscopy: Erosive Gastritis • 10 pack‐years smoking • Drinks alcoholic beverage for 8 years

  8. Clinical Impression • Perforation due to PUD

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