CASE WRITE UP

FACULTY OF MEDICINE

CRITICAL CARE DEPARTMENT

Name : Law Shen Hong

Student ID : BMS 19096163

Group :3

Posting : Critical Care

1. Patient Information

Name: Noor Dah Sam binti Ahmad

Age: 70-year-old
Gender: Female
Ethnic: Malay
Date of admission into ICU: 22/11/2022

2. Background

a) History Taking

Patient has underlying diabetes mellitus, hypertension and dyslipidemia. She

was well until 3 days ago and admitted into the Emergency Department on
20/12/2022 at 0430H. She complained of abdominal pain for the past 1 day
which was sudden in onset, sharp pain in nature with a pain score of 8/10 at
epigastric and right hypochondriac region. It was associated with nausea and 1
episode of vomiting. Otherwise, she has no fever, no chest pain, no shortness
of breath, no history of trauma and no history of urinary tract infection. She
revealed the history of hysterectomy which was done 20 years ago. She had a
history of diabetes mellitus, hypertension and dyslipidemia and admitted to
being on one oral antihyperglycemic drug, one antihypertensive drug and one
statin, however, she was unsure of the drug names and claimed to be
compliant. She admitted to having a history of purchasing over-the-counter
painkillers for the past two years. She had no known drug and food allergy. No
significant family history and social history revealed the patient is married,
unemployed, non-smoker and non-alcoholic drinker.

b) Physical Examination

General examination: Alert, conscious and cooperative. GSC is full.

Vital signs: Pulse rate at 98 beats per minute, respiratory rate at 16 breaths per
minute, blood pressure at 164/74 mmHg, spO2 100% at room air and
temperature at 37°C.
Cardiovascular examination: Dual rhythm no murmur
Respiratory examination: Lung clear. Vesicular breathing with equal air entry
on both sides of the chest.
Abdominal examination: Soft and nondistended abdomen with tenderness over
epigastric region.

c) Investigation sent
I. Before admission (in ED)
Complete blood count, Coagulation profile, Blood urea and serum
electrolyte (BUSE) and arterial blood gas (ABG).
 II. On admission (in ICU)
Complete blood count, renal profile, coagulation profile, liver function
tests, cardiac enzymes test, group, screen and hold (GSH), group
checking and matching (GXM), blood urea and serum electrolyte
(BUSE), venous/arterial blood gas, chest X-ray, and abdominal X-ray.

d) Cause of referral to ICU

Intensive intervention. Intervention to manage the septic shock secondary to
perforated gastric ulcer.

3. Course of case from admission

a) Provisional or differential diagnosis

Septic shock secondary to perforated gastric ulcer.

b) Monitors used and rationale

Purposes Monitor Used Rationale

To ensure adequate inspired oxygen concentration
Oxygen analyzer
in the patient.
Oxygenation
To ensure adequate oxygen concentration in the
Pulse oximeter
blood.
To continuously measure and analyse end-tidal
Capnography carbon dioxide when the patient was intubated,
Ventilation and determine the adequacy of ventilation.
Respiratory rate To monitor adequate ventilation of the patient.
To monitor cardiac electrical activity of the
Electrocardiogram
patients
Non-invasive Blood
Circulation To monitor blood pressure of the patients.
Pressure
Heart rate
To monitor the circulatory function of the patient.
Pulse rate
To detect thermal disturbances and maintain
Temperature Thermometer (Axillary)
appropriate body temperature.

c) Management
I. Essential care

Essential care Management

Feeding / Fluid Feeding :
 ● Patient was on enteral feeding via nasogastric tube.
Fluid Management :
● Arterial line was set up on the right radial artery.
● IV fluid was dripped with a pressure bag (white pump bag).
● 5% Dextrose and IV Sterofundin was given to the patient
Analgesia ● Patient was given Morphine

Sedation ● Sedation was sedated with Midazolam.

Thromboprophylaxis ● Patient was given SC Enoxaparin (Clexane) 60 mg 12 hourly for

5 days
Head elevation ● Patient’s head was elevated at 35o
Stress ulcer Patient was given IV Pantoprazole 40mg (Proton Pump Inhibitor)
prophylaxis
Glucose control Patient was given insulin.

II. Specific care

(a) Airway management
Endotracheal tube intubation.
Type: PVC and cuffed.
Size 7.5.

(b) Ventilatory management

Synchronised intermittent mandatory ventilation (SIMV).
Ventilator type: PB 840
Humidifier using heat and moisture exchanger (HME) filter.
Keep FiO2 at 50% and respiratory rate at 20 breaths per
minute.

d) Course of Vital signs

21/12/2022 22/12/2022
at 0800H at 0800H

Temperature (℃) 37.0 (Axillary) 36.2 (Axillary)

Heart rate 97 92
(beat/min)

Blood pressure 97/80 113/65

(mmHg)

SpO2 (%) 100 95

Respiratory rate 20 20
(breath/min)
 e) Course of fluid input/output chart

f) Any critical event

Uneventful.

g) Outcome of patient
Slight improvement of vital signs. However, the patient is unconscious and
under ventilation with a GCS score that is still very poor at 3/15.

4. Discussion

Perforated gastric ulcer is a complication of peptic ulcer disease. Peptic ulcer disease
refers to an ulcer in the lower oesophagus, stomach or duodenum, in jejunum after
surgical anastomosis to the stomach or, rarely, in the ileum adjacent to a Meckel’s
diverticulum. The predisposing factors of peptic ulcer are Helicobacter pylori
infection, overuse or misuse of non-steroidal anti-inflammatory drugs (NSAIDs),
smoking, alcohol consumption, stress and gastric hypersecretion in cases of
Zollinger-Ellison syndrome. The clinical features of peptic ulcer disease depend on
the site of the ulcer. Gastric ulcer occurs in the stomach presented with epigastric pain
after eating, hematemesis, melena, heartburn, chest discomfort, early satiety and can
lead to gastric carcinoma. On the other hand, duodenal ulcer presented with epigastric
pain after eating, pain awakens patient during night and less commonly presented
 compared to gastric ulcer are heartburn, chest discomfort, melena and hematochezia.
Diagnosis of perforated peptic ulcer disease can be made by history taking, physical
examination, upright chest radiograph with findings of free air under diaphragm and
computerised tomography (CT) scan. Acute perforation can be treated surgically,
either by simple closure, or by converting the perforation into pyloroplasty if it is
large. Following surgery, Helicobacter pylori should be treated if present and NSAIDs
should be avoided. Complications of perforated gastric ulcer are abdominal distension
resulting from peritonitis and subsequent ileus. Postoperative complications are
around the anastomosis including obstruction, leaks, bleeding, esophagitis and
alkaline reflux gastritis and vomiting. Other complications postoperatively are
problems due to vagus nerve transection, loss of stomach capacity and function. In
this case, patient came to ED with complaint of intense sharp abdominal pain for past
1 day with pain score of 8/10 and a history self-purchasing NSAIDs without
prescription gave a hint of probable peptic ulcer disease and eventually confirmed the
diagnosis of perforated gastric ulcer after investigations and was sent to operating
theatre for emergency surgical intervention. However, postoperatively, the patient is
hemodynamically unstable with postoperative fever. Therefore, sent to a high
dependency unit to be admitted in an intensive care unit for intensive intervention as
the condition of patient was deteriorating.

ICU admission criteria

Criteria In this patient
Prioritization according to the patient’s severity of illness /
Specific patient needs such as life-supportive therapies /
Diagnosis /
Prognosis /
Potential benefit from interventions /
Objective parameters at the time of referral /
Available clinical expertise /
Bed availability /

Indication of ICU admission

Indication In this patient
Intensive monitoring
Intensive interventions /
Organ preservation in brain death patient for organ donation
5. References
I. Colledge, N.R., Walker,B.R. and Ralston, S.H., (2010). Davidson’s Principles
and Practices of Medicine (21st Edition). Churchill Livingstone Elsevier.
II. Kumar, P. and Clark, M.L., 2020. Kumar and Clark's Clinical Medicine (10th
Edition). Elsevier Health Sciences.
III. ICU Management Protocols by Malaysian Ministry of Health & Malaysian
Society of Intensive Care.