A Case Report: Upper Gastrointestinal Bleeding in a 58 y/o Alcoholic Patient with Stigmata of Chronic Liver Disease

MCU – FDTMF HOSPITALDepartment of Internal Medicine

JI Joshua Balunsay-Camaing PGI John Paul BenitezJI Prima Donna Estorninos PGI Joyce David

JI Allen Jurado PGI Justin Melissa DurezaJI Tara Angela Krysteena Oliveros-Dela Cruz PGI Juliet Kristine EvangelistaJI Laura Angela Palisoc-Saberola PGI Julie GayonJI Elizabeth Jeremmie Reyes

1.To present a case of Upper Gastrointestinal Bleeding with Laennec’s Cirrhosis

2.To differentiate Upper Gastrointestinal Bleeding from Lower Intestinal Bleeding and Swallowed Blood from Massive Hemoptysis or Epistaxis

3.To identify the tell tale signs of Liver Cirrhosis present in our case

LEARNING OBJECTIVES

4.To establish the possible causes of Upper GI bleeding in the setting of Laennec’s Cirrhosis

5.To devise strategy on how to diagnose and manage Upper GI Bleeding in the setting of Laennec’s Cirrhosis.

LEARNING OBJECTIVES

• D. E.• 58-year-old, Male, Widower• Filipino, Roman Catholic• Retired jeepney driver• Bulacan resident• First admission at MCU-

FDTMF Hospital on June 24, 2012

GENERAL DATA

CHIEF COMPLAINT

Melena

HISTORY OF PRESENT ILLNESS

1 year PTA

• Abdominal enlargement

• Abdominal fullness

• Consult

• Ultrasound & Endoscopy done

• Lost to follow-up

HISTORY OF PRESENT ILLNESS

6 months PTA

• Previous symptoms

• Jaundice• Flank pain• Consult/Admitted• Shockwave

Lithotripsy, Left was done

• Discharged

HISTORY OF PRESENT ILLNESS

5 months PTA

• Regular follow-up

• Dyspnea • Admitted• COPD • Liver Cirrhosis• Discharged

HISTORY OF PRESENT ILLNESS

4 months PTA

• Regular follow-up• Abdominal

enlargement, jaundice, & dyspnea

• Liver Function Tests were done

• Home medications• Lost to follow up

HISTORY OF PRESENT ILLNESS

1 day PTA• Previous

symptoms persisted

• Hematemesis• Body weakness• Consult

HISTORY OF PRESENT ILLNESS

• Melena

• Consult

• ADMISSION

Few hours PTA

PAST MEDICAL HISTORY

(+) Hypertensive – for 6 months• Amlodipine 10 mg/tablet once a day• (+) good compliance• Usual BP = 120/80 Highest BP =170/100

(+) Previous Hospitalizations

No blood transfusion

(+) Hypertension – paternal

FAMILY HISTORY

• 30 pack year smoking history

• 1 bottle of gin 2-3 times a week or sometimes 5-6 bottles of beer 3-4 times a week for almost 40 years

• Sedentary lifestyle

• Unrestricted diet

PERSONAL & SOCIAL HISTORY

(+) weight gain, (+) poor appetite, (+) easy fatigability

(-) rashes, (-) change in color of moles

(-) headache, (-) dizziness, no blurring of vision(-) tinnitus, (-) hearing loss, (-) ear discharge, (-) colds

REVIEW OF SYSTEMS

General

Skin

HEENT

(-) hemoptysis, (+) dyspnea, (-) cough

(+) orthopnea, (+) paroxysmal nocturnal dyspnea, (-) palpitations

(-) abdominal pain, (-) dysphagia, (-) diarrhea, (-) constipation, (-) hematochezia, (-) vomiting

REVIEW OF SYSTEMS

Chest & Lungs

Heart

Abdomen

(-) polydipsia, (-) polyuria, (-) polyphagia, (-) nocturia, (-) hematuria, (-) dysuria

(-) diaphoresis, (-) seizures, (-) loss of consciousness, (-)sensorial changes

REVIEW OF SYSTEMS

Genito-urinary

Neurologic

General Survey:

Patient is chronically-ill, alert, large built, 5’7” in height, weighing 95 kg and BMI of 32 kg/m2, with labored breathing, brown skin with yellowish-tinge, and slightly slurred speech. He is sad-looking and has a depressed mood. He is clad in a white hospital gown. He exudes an malodorous scent. His hair is short and well-kempt. He is lying on his bed. He has difficulty in getting-up. He has spontaneous movements with no tics or mannerisms. He has no gross deformities.

PHYSICAL EXAMINATION

PHYSICAL EXAMINATION

Vital Signs:

BP: 110/70Temperature: 36.9CHeart Rate: 77 bpmRespiratory Rate: 22/rpmPain Scale: 0/10

PHYSICAL EXAMINATION

Skin

icteric, dry, coarse, warm, elastic & has good skin turgor, (+) 2-3mm petechiae scattered on his left upper chest red in color that blanched on pressure. Hair is black, short, coarse, and is equally distributed, (+) Terry’s nails with clubbing

PHYSICAL EXAMINATION

HEENT:

HeadRound-shaped, symmetrical with abundant, equally distributed hair, no lesions in the scalp, no area of tenderness, symmetrical face. Facial skin color is icteric with no areas of hyper-or hypopigmentations, with no lesions.

PHYSICAL EXAMINATION

HEENT:EyesEyes are symmetrically aligned, Eyebrows and Eyelashes are thick and fairly distributed, No periorbital scaliness or edema, No lumps or swelling of the lacrimal apparatus, Icteric sclerae and palpebral conjunctiva, No opacities of the cornea and lens, Iris is fairly flat, casting no shadows, Pupil size is 4 mm equally reactive to light, constricting to 2 mm, intact direct and consensual reaction, Intact extraocular movement and convergence test, disc margins sharp; no haemorrhages or exudates, No arteriolar narrowing

PHYSICAL EXAMINATION

HEENT:

EarsSymmetrical, (-) deformity of the auricle, Right and left canals are both clear of wax, TM with good cone of light, Acuity good to whispered voice, Sound is equally heard in both ears during Weber’s test, AC>BC

PHYSICAL EXAMINATION

HEENT:

Nose(+) alar flaring, symmetrical, (-) deformity, obstruction, pink mucosa, septum is midline

PHYSICAL EXAMINATION

HEENT:

ThroatPale and dry lips, (-) canker sores, (+) dental caries and poor dentition, roof of the mouth is hard, whitish tongue, No sores on the floor of the mouth, No tonsilopharyngeal congestion

PHYSICAL EXAMINATION

Neck:

Broad & short neck, supple on all movements, No lesions, no neck vein engorgement• (-) cervical lymphadenopathy• Midline trachea• Thyroid gland is about 15 grams• (-) carotid bruit

Chest/Lungs

• Symmetrical, (+) gynecomastia, (-) cyanosis• (-) audible wheezing or stridor• (-) contraction of the accessory muscles• Transverse diameter is much wider than the AP

diameter• Symmetric chest expansion, (+) retractions, (-)

lagging• (-) masses, (-) tenderness, tactile fremitus is

equal in both lungs, • Resonant both in anterior and posterior• Vesicular breath sounds, (-) crackles, wheeze or

rhonchi• (-) bronchophony, egophony and whispered

pectoriloquy

PHYSICAL EXAMINATION

Heart

• Adynamic precordium, (-) visible pulsations, apex beat is at 5th ICS, left MCL, (-) scars, lesions, signs of trauma and previous surgery, (-) precordial bulging

• JVP is 3 cm above suprasternal angle• Apex beat is palpable in the 5th ICS

midclavicular line. Size is about 2 cm and tapping

• Crisp S1 and S2, at the base, S2>S1, at the apex S1>S2

• (-) murmurs

PHYSICAL EXAMINATION

Abdomen:

• Abdomen is globular, shiny & tensed, icteric skin, with visible dilated superficial abdominal veins, everted umbilicus, Abdominal girth=42 inches

• (+) normoactive bowel sounds, (-) abdominal, lumbar, and iliac bruit, (-) friction rubs

• (-) palpable masses• Liver edge is knobby, (+) rebound tenderness on

Left Upper Quadrant, liver span=8.0 cm Right MCL

• Traube’s space is dull, rest of the abdomen is tympanitic

• (+) shifting dullness, (+) fluid wave test

PHYSICAL EXAMINATION

Peripheral Vascular

• Extremities are warm• (+) bipedal edema• No varicosities or stasis changes• Calves are supple and nontender• (-) femoral or abdominal bruits• Brachial, radial, femoral, popliteal, dorsalis

pedis (DP), and posterior tibial (PT) pulses are 2+ and symmetric

PHYSICAL EXAMINATION

Back and Spines

• Symmetrical• (-) spasm and tenderness of the

paravertebral and back muscles

PHYSICAL EXAMINATION

Extremities

• Paired joints are symmetrical• (+) bipedal edema• (-) evidence of redness, skin rash,

subcutaneous nodules, cysts, scars• (-) tenderness upon firm pressure along the

joint margins, and over tendons and ligaments• Full range of motion

PHYSICAL EXAMINATION

Neurological:

CEREBRAL• Alert but appears anxious• Speaks in soft tone • Thought is coherent and oriented to person,

place and time• (-) aphasia, executed verbal commands with

slight limitation• Responds to questions correctly and was able to

repeat short sentences• Able to calculate simple arithmetic problems• Memory to both remote and recent is intact, no

agnosia, no apraxia

PHYSICAL EXAMINATION

Neurological:

Cranial NervesI intact sense of smellII pupils equally reactive to light and

are 2-3 mm constrictedIII, IV, VI intact extraocular musclesV intact corneal reflexVII (-) facial asymmetryVIII intact hearingIX, X intact gag reflexXI can shrug shouldersXII tongue is at midline

PHYSICAL EXAMINATION

Neurological:

Motor(-) atrophy of the muscles of both upper and lower extremities, good muscle tone

Motor StrengthRight upper extremities: 5/5Left upper extremities: 5/5Right lower extremities: 3/5Left lower extremities: 3/5

Sensory: Light touch, vibration and sharp or dull pain sensation, and stereognosis are 100% intact throughout the body

PHYSICAL EXAMINATION

Neurological:

CerebellarRapid alternating movements, finger-to-nose, heel-to-shin test intact (-) pronator driftTandem walking revealed no ataxia

(-) Babinski reflex

PHYSICAL EXAMINATION

SALIENT FEATURES

• 58 y/o male• Smoker & heavy

alcoholic beverage drinker

• melena• Abdominal

enlargement & fullness• Icteresia• Hematemesis• Hypertensive

• Easy fatigability, dyspnea, orthopnea, PND

• Petecchial rashes• Terry’s nails with

clubbing• Globular, shiny, everted

umbilicus• Visible superficial

abdominal veins• Liver edge is knobby• Dullness on Traube

space• Bipedal edema

TELL TALE SIGNS OF ALCOHOLIC CIRRHOSIS

-Variceal bleeding -hepatic encephalopathy-Edema-icteresia-ascites-spider angioma-Caput medussae-palmar erythema-Gynecomastia

CLINICAL FEATURES

SOURCE OF BLEEDING

RESPIRATORY TRACT vs GI TRACT

RESPIRATORY TRACT

FrothypH is basic

Preceded by coughEvidence of epistaxis or gum

bleedingSwallowed and appear as

melena or occult blood in stool

GASTROINTESTINAL TRACT

pH is acidic

HematemesisMelena

hematochezia

UGIB VS LGIB

SOURCE OF BLEEDING?

UPPER GI TRACT

HematemesisMelenaHematochezia (massive

bleeding >1000ml)Increased Transit Time

LOWER GI TRACT

HematocheziaMelena if with altered

bowel function (constipation) or obstruction, from proximal colon

• Quantity and Duration – most important risk factors in the development of alcoholic liver disease

• 1 beer = 4 ounces of wine = 1 ounce of 80% spirits = 12 g of alcohol

• Threshold (men) – intake >60-80g/d for 10 years

• Threshold (women) – intake >20-40/d for 10 years

Harrison’s Principles of Internal Medicine, 17th Edition. McGraw-Hill Companies, Inc., USA: 2008. p 1969.

ABOUT ALCOHOLISM

• Ingestion of 160g/d – 25-fold increased risk for alcoholic cirrhosis

• 20-50g/d – increased risk for Cirrhosis and Hepatocellular Ca in patients with HCV infection

Harrison’s Principles of Internal Medicine, 17th Edition. McGraw-Hill Companies, Inc., USA: 2008. p 1969.

ABOUT ALCOHOLISM

• Blood Alcohol Concentration of 80-100 mg/dL – legal definition for driving under influence of alcohol

• 3 oz. (44ml) of ethanol in 77-kg person = 12 oz. of fortified wine = 8 bottles of beer (12 oz. each) = 6 oz. of 100-proof whiskey

• Habitual drinkers – can tolerate up to 700mg/dL

Robbins and Cotran Pathologic Basis of Disease , 8th Edition. Elsevier, Inc., USA: 2008. p 421-422.

Katzung Basic and Clinical Pharmacology, 11th Edition. McGraw-Hill Companies, Inc., USA: 2010. p 365.

ABOUT ALCOHOLISM

• 100-200 mg/dL – impaired motor function, slurred speech, ataxia

• 200-300 mg/dL – emesis, stupor• 300-400 mg/dL – coma• >500 mg/dL – death, respiratory

arrest

Robbins and Cotran Pathologic Basis of Disease, 8th Edition. Elsevier, Inc., USA: 2008. p 421-422.

Katzung Basic and Clinical Pharmacology, 11th Edition. McGraw-Hill Companies, Inc., USA: 2010. p 365.

ABOUT ALCOHOLISM

STIGMATA OF LIVER CIRRHOSIS

Risk Factors for Alcoholic Liver Disease

1. Quantity – In men, 40-80g/day produces fatty liver; 160g/day in 10-20 years causes hepatitis or cirrhosis

2. Gender – Women>men3. Hepatitis C Infection

PATHOPHYSIOLOGY

Risk Factors for Alcoholic Liver Disease

4. Genetics – genetic polymorphisms (alcohol dehydrogenase, cytochrome p4502E1, and those associated with alcoholism)

5. Malnutrition – Obesity and fatty liver from effect of CHO on transcriptional control of lipid synthesis and transport

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY

Results:1. Acetaldehyde adducts

formation2. Increase ROS formation3. Increase NADH:NAD+

formation

PATHOPHYSIOLOGY

Chronic Alcoholism

↑ reduced NADH

Impaired assembly and secretion of

lipoproteins

↑ peripheral catabolism of

fat

↑ lipid biosynthesis

Gross accumulation of fat in liver cells

↑ FA uptake& ↓ FA

oxidation

PATHOPHYSIOLOGY

Chronic Alcoholism

Decreased intrahepatic GSH levels

Oxidative injury to liver

Induction of Cytochrome P-

450

Production of ROS

React with cellular proteins forming

protein-acetaldehyde

adducts

Interfere with specific enzyme activities

Alter hepatocellular function (microtubular formation & protein

trafficking)

Kupffer cell activation

PATHOPHYSIOLOGY

Continuing alcohol ingestion

Progressive hepatocyte injury (ballooning degeneration, spotty necrosis, PMN infiltrate and

fibrosis in the perivenular and perisinusoidal space)

Liver fibrosis and scarring

Decreased liver function

Obstruction of portal circulation

Portal Hypertension

(>5 mmHg HVPG)

Liver contracts

and shrinks

PATHOPHYSIOLOGY OF ESOPHAGEAL VARICES

Deranged (vascular) architectur

eVasoconstrictor (dilator) imbalance

• Adrenergic System

(increased cardiac index)• RAA System (renal sodium-water retention

• Increased portal blood

flow• Increased resistance to portal flow

PATHOPHYSIOLOGY OF ASCITES

Portal Hypertension

Splanchnic vasodilation

↑ Splanchnic pressure

Arterial underfilling

Lymph formation

Formation of peripheral edema & ascites

Plasma volume expansion

Activation of vasoconstrictors

and antinatriuretic

factorsSodium

retention

Hypoalbuminemia & ↓ Plasma

oncotic pressure

PATHOPHYSIOLOGY

Portal Hypertension

Congestive splenomegaly

Hypersplenism

Thrombocytopenia

LUQ pain

Diversion of portal blood to systemic

circulation

Venous collateral

shunt

Caput medussae

Digital Clubbing

Testicular atrophy

Direct toxic effect of alcohol

Hormonal abnormalitie

s

GynecomastiaDecreased body

hairSpider

angiomatasPalmar Erythema

PATHOPHYSIOLOGY

Decreased Liver Function

↓ Bilirubin uptake and storage

Hyperbilirubinemia

Icteric sclera

Jaundice

↓Clotting factors

Bleeding tendencies

Anemia

↓ protein production

Hypoalbuminemia

Terry’s NailsMuehrcke's

lines

PATHOPHYSIOLOGY

Decreased Hepatic

Mass

Impaired removal of Gut-derived neurotoxins

Altered mental statusAsterixis

Vascular Shunting

↑Ammonia levels

ComaDeath

PATHOPHYSIOLOGY

1.Bleeding Esophageal Varices2.Gastric/Duodenal Varices

(Portal Hypertensive Gastropathy)3.Gastroduodenal Ulcer4.Mallory-weiss Tears5.Erosive Gastritis

CAUSES OF UGIB IN THE SETTING OF ALCOHOLIC

LIVER DISEASE

Erosive Gastritis• Rule In:• (+) melena• Rule Out:• Chronic alcohol consumption is not a

common cause of erosion in the gastrointestinal tract

• More commonly related with NSAID abuse

CAUSES OF UGIB IN THE SETTING OF ALCOHOLIC

LIVER DISEASE

Gastroduodenal Ulcer• Rule In:• (+) melena

• Rule Out:• More commonly associated with

H.pylori infection and chronic NSAID intake

CAUSES OF UGIB IN THE SETTING OF ALCOHOLIC

LIVER DISEASE

Mallory-Weiss Tears• Rule In:• (+)melena, (+) chronic intake of alcohol• Rule Out:• Bleeding usually occurs immediately after

recent history of severe retching or vomiting

• Commonly presents as hematemesis

CAUSES OF UGIB IN THE SETTING OF ALCOHOLIC

LIVER DISEASE

Gastric/Duodenal Varices (Portal Hypertensive Gastropathy)

• Rule In:•(+) melena, (+) chronic alcoholism, (+) prominent superficial veins

• Rule Out:• Less common in patients with history of chronic alcohol intake

CAUSES OF UGIB IN THE SETTING OF ALCOHOLIC

LIVER DISEASE

Bleeding Esophageal Varices• Rule In:• (+) melena, (+)chronic alcohol intake

• Most Common cause of upper GI bleeding in the setting of alcoholic liver cirrhosis

• Strongest tendency to bleed

CAUSES OF UGIB IN THE SETTING OF ALCOHOLIC

LIVER DISEASE

Definitive Diagnosis is by Esophagogastroduodenoscopy (EGD)

CAUSES OF UGIB IN THE SETTING OF ALCOHOLIC

LIVER DISEASE

UPPER GASTROINTESTINAL BLEEDING

secondary to Bleeding Esophageal Varices

ADMITTING IMPRESSION

APPROACH TO PATIENTAT THE EMERGENCY ROOM

• Hematemesis

• Melena

• VS: BP-120/70

• PR=77 bpm

• RR=22 rpm

• T=36.9ºC• Chronically

ill-looking

UGIB secondary to Bleeding Esophageal Varices

• Admit to MMW

• VS q2, I&O qshift

• IVF D5NM 1L X 60cc/hr

• NPO except medications

• CBC, Na, K, Crea, CBG q6, ECG, CXR

• Pantoprazole drip at 6mg/hr

• Lactulose syrup 30cc BID

• Standby 2U PRBC

• For EGD once stable

S O A P

LABORATORY RESULTS

COMPONENT RESULT REFERENCE

RBC 3.19 x 10 ^12/L 4.6 – 6.20

Hemoglobin 12.10 g/dL 13.5 – 18.0

Hematocrit 0.37 0.42 – 0.50

WBC 12.3 x 10^9/L 4.5 – 11

Segmenters 0.77 0.56

Lymphocytes 0.20 0.34

Monocytes 0.01 0.04

Platelet count Decreased 150 – 400

MCV 115.7 fl 80 – 96

MCH 38 pg 27 – 31

MCHC 0.33 0.32 – 0.36

CBC

LABORATORY RESULTS

CBG = 7.5 mmol/L

Clinical Chemistry

RESULT REFERENCE

Creatinine 0.89 mg/dl 0.60-1.20

Sodium 132.1 mmol/L

135-148

Potassium 2.74 mmol/L 3.5-5.3

LABORATORY RESULTS

CHEST XRAY• Lung fields are clear• Heart is not enlarged• The right hemidiaphragm is

elevated• Both sulci are intact

IMPRESSION:• Elevated right

hemidiaphragm

LABORATORY RESULTS

12 LEAD ECG• Sinus tachycardia• Non specific ST-T wave

changes

• Weakness, dizziness, syncope associated with hematemesis and melena

• A brisk UGIB manifests as hematochezia

• History of dyspepsia, ulcer disease, early satiety, and NSAID or aspirin use

• Prior history of ulcers

APPROACH TO PATIENT WITH GI BLEEDING

HISTORY

• In a more subacute phase, with a history of dyspepsia and occult intestinal bleeding

• History of chronic alcohol use of more than 50 g/d or chronic hepatitis (B or C)

• Subcutaneous emphysema with a history of vomiting (Boerhaave syndrome)

• Presence of postural hypotension

APPROACH TO PATIENT WITH GI BLEEDING

HISTORY

GOAL: To evaluate for shock and blood loss• Assess the patient for hemodynamic instability and clinical

signs of poor perfusion

Hemodynamic compromise:

• tachycardia of more than 100 bpm

• Systolic BP <90 mm Hg

• cool extremities

• Syncope

• other obvious signs of shock

TILT Test• Signs of chronic liver disease including spider angiomata,

gynecomastia, increased luneals, splenomegaly, ascites, pedal edema, and asterixis

• Signs of tumor: nodular liver, an abdominal mass, and enlarged and firm lymph nodes

APPROACH TO PATIENT WITH GI BLEEDING

PHYSICAL EXAMINATION

COURSE IN THE WARDDAY OF ADMISSION

• Difficulty of Breathing

• Melena

• VS: BP=100/70

• PR=100 bpm

• RR=23rpm• T=36.0ºC• Chronically

ill-looking

UGIB secondary to BEV

• KCl drip at 5 mEq/hr

• Furosemide 20mg/IV

S O A P

COURSE IN THE WARD1ST DAY OF HOSPITALIZATION

• Difficulty of Breathing

• Hematemesis

• Melena

• Refused transfer to MICU-CD

• VS: BP=90/60

• PR=120 bpm

• RR=26rpm• T=37.3ºC• Chronically

ill-looking

UGIB secondary to BEV

• For transfusion of 1 unit PRBC

• Transfer to MICU-CD

• Transfuse 4 U FFP

• Somatostatin drip PNSS 250cc + 3mg X 12hrs

• Somatostatin 250 mcg/IV

• Lactulose 30cc TID

• Vit K 10mg/amp, q8 X 3 days

• Repeat CBC with APC

S O A P

LABORATORY RESULTS

COMPONENT RESULT REFERENCE

RBC 3.21 x 10 ^12/L 4.6 – 6.20

Hemoglobin 12.20 g/dL 13.5 – 18.0

Hematocrit 0.37 0.42 – 0.50

WBC 12.34x 10^9/L 4.5 – 11

Segmenters 0.88 0.56

Lymphocytes 0.09 0.34

Monocytes 0.03 0.04

Platelet count Reduced 150 – 400

MCV 114.9 fl 80 – 96

MCH 38 pg 27 – 31

MCHC 0.33 0.32 – 0.36

CBC

LABORATORY RESULTS

PT = 37.7 secs (12-14 sec)

PA = 36.9% (100%)Control: 13.9 secs

INR = 3.95 (RV 1.0-1.3)

PTT = 40.7 secs (Control 29.5 secs)

COURSE IN THE WARD2ND DAY OF HOSPITALIZATION

• Hematemesis

• Hematochezia 2x

• (+) easy fatigability

• Refused Intubation

• VS: BP=119/71

• PR=137 bpm

• RR=36rpm• T=36.8ºC• Awake,

weak-looking

UGIB secondary to BEV

• Repeat PTPA after last dose of Vit K

• Continue KCl drip

• Levofloxacin 500mg/IV OD

• For gastroscopy

• Standby 2 units PRBC

S O A P

LABORATORY RESULTS

COMPONENT RESULT REFERENCE

RBC 2.2 x 10 ^12/L 4.6 – 6.20

Hemoglobin 8.4 g/dL 13.5 – 18.0

Hematocrit 0.26 0.42 – 0.50

WBC 17.3x 10^9/L 4.5 – 11

Segmenters 0.90 0.56

Lymphocytes 0.08 0.34

Monocytes 0.02 0.04

Platelet count 77 150 – 400

MCV 116 fl 80 – 96

MCH 38.3 pg 27 – 31

MCHC 0.33 0.32 – 0.36

CBC

LABORATORY RESULTS

Serum Potassium = 2.60 mmol/L

PT = 29.9 secs (12-14 sec)

PA = 49.1% (100%)Control: 13.3 secs

INR = 2.99 (RV 1.0-1.3)

LABORATORY RESULTS

DATE & TIME CBG RESULTS

6/22/12 – 7:13 pm 7.5 mmol/L

6/22/12 – 12:00 am 7.7 mmol/L

6/23/12 – 06:00 am 5.4 mmol/L

6/23/12 – 12:00 pm 5.9 mmol/L

6/22/12 – 06:00 pm 6.3 mmol/L

6/24/12 – 12:00 am 7.2 mmol/L

6/24/12 – 06:00 am 8.1 mmol/L

6/24/12 – 12:00 pm 7.8 mmol/L

6/24/12 – 06:00 pm 7.3 mmol/L

6/25/12 – 12:00 am 7.5 mmol/L

6/25/12 – 06:00 am 7.3 mmol/L

COURSE IN THE WARD3RD DAY OF HOSPITALIZATION

• Difficulty of Breathing

• Refused Intubation

• VS: BP=120/80

• PR=170 bpm

• RR=27rpm• T=37.0ºC• O2

sat=70%• (+)

Crackles both lung fields

UGIB secondary to BEV

• Hold gastroscopy

• Lactulose 30cc q6

• Hold CBG monitoring

• Spironolactone 25mg/tab, OD

• Digoxn 0.25mg/IV, ½ ampule

• O2 at 10LPM via face mask

• Furosemide 20mg/IV

• For ABG’s now

S O A P

COURSE IN THE WARD4TH DAY OF HOSPITALIZATION

• Difficulty of Breathing

• Refused Intubation

• VS: BP=120/80

• PR=170 bpm

• RR=27rpm• T=37.0ºC• O2 sat=50-

70%• (+)

Crackles

• CLINICALLY DEAD at 3:43am

UGIB secondary to BEV

• Bicarbonate 150 mEqs slow IV push

• Do rhythm strip

• Post-mortem Care

S O A P

UPPER GASTROINTESTINAL BLEEDING secondary to

BLEEDING ESOPHAGEAL VARICES

ALCOHOLIC LIVER DISEASE

FINAL DIAGNOSIS