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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