Gastrointestinal Bleeding – Protocol #1
Monday,
January 8, 2001
10:30 AM –
12:30 AM
Chief Complaint: “I’m passing black stools
and am lightheaded for the past three days”.
History of Present Illness: MD is a 64 y/o/m advertising executive who presents of the
Emergency Room with the complaint of passing black stools for the past three
days and an associated lightheadedness.
He also relates that he can not keep up with his usual schedule because
of easy fatiguability. Upon further
questioning, he states that his stools are not only black, but they are
‘sticky’ and ‘malodorous’. He complains
also of recent worsening of his chronic epigastric burning which has been a
problem on/off for the past several years.
He has doubled his daily dose of Tums but has not noticed any
significant relief of his burning. He
drinks 2-3 martinis at lunch with clients and has another cocktail or glass of
wine with dinner. He uses Nsaid’s prn
for a back injury and recently was started on one aspirin (low dose) daily for
cardiac prophylaxis. He smokes two
packs of cigarettes for the past twenty years and has an occasional cigar. In the distant past he was told of a ‘ulcer’
but had no specific treatment or evaluation.
MM
has been treated for hypertension for the past 8 years. He denies previous cardiac history and has no
exertional chest pain. His weight is
stable and his appetite is excellent.
He has a normal daily bowel movement and has not had prior black
stools. He has had no abdominal
surgery. No bleeding tendency. No transfusions.
Physical Examination:
GENERAL/VITALS: Physical examination reveals an alert, oriented, overweight male who appears stated age. He is anxious and restless. Vital signs (supine): B/P=120/84 mm Hg,
HR=110/min Vital signs (standing): B/P= 90/60 mm Hg. HR=140/min. Pt. complains
of dizziness upon standing.
Respirations=20/min. Temp=98.6
F.
HEENT/Skin: Facial pallor. Cool, moist skin. No
telangiectasia of lips or oral cavity.
No spider nevi. Parotid glands
are full.
CHEST: Lungs are clear to
auscultation/percussion. Cardiac exam
reveals regular rhythm, fourth heart sound present. No murmurs. Peripheral
pulses are weak.
ADBOMEN/RECTUM: Abdomen is rounded. Bowel sounds are hyperactive. Moderate tenderness to deep palpation in the
epigastrium. Liver is percussed to 13
cm and the edge is felt and feels firm.
No splenomegaly. Rectal reveals
black, sticky stool.
Laboratory evaluation: Hemoglobin=9 gm/dl, hematocrit=27%, MCV=90, WBC=13.000/cmm, PT(INR)/PTT=nl, BUN=
45 mg/dl, Creatinine= 1 mg/dl,
Chest
X-ray=nl, Plain films of abdomen=nl.
Gastrointestinal
Bleeding – Protocol #1
1.
Define
all unknown terms in the protocol.
2.
What
is the major clinical problem (not the diagnosis)?
3. Develop a differential diagnosis for the problem.
4. Discuss the likely diagnosis. Cite data to support your diagnosis.
5. List the causes if non-bloody black stools.
6. What physical finds and lab data support a diagnosis of acute bleeding?
7. What amount of blood loss is required to produce each of the following: occult positive stool? melena? orthostasis?
8. Prioritize steps that would likely be taken in the ER to treat this patient.
9. A nasogastric tube was placed by the ER resident. The aspirate reveals a clear return. What does this mean? Does this change or alter your diagnosis?
10. A gastroenterologist is in the ER seeing another patient. You ask him about the case and he recommends an upper GI endoscopy. Do you agree?
11. List factors that increase the mortality and morbidity from UGI bleeding.
Gastrointestinal Bleeding – Protocol #2
10:30 AM –
12:30 AM
Chief Complaint: “ My bowel don’t move right.”
History of Present
Illness: MM is a 73 y/o/f who complains of a significant change in her
bowel habits during the past 6 weeks.
She describes her bowel movements as regular, once /day, up until 6
weeks ago. For the past 6 weeks she
experienced 3-4 day periods of constipation alternating with non-bloody diarrhea. Although most of her bowel movements
resulted in formed stools which were brown in color and of normal caliber,
three days ago she passed a stool with streaks of blood on the surface. The patient was not alarmed because she has
suffered from bleeding hemorrhoids in the past.
During
the periods of constipation she feels bloated and has mild discomfort in the
lower abdomen. The pain is relieved
with defecation. She admits to a few
pounds of weight loss but has decreased her intake to ‘keep my weight
down’. She describes her health as good
and states that she tires easily on some days.
She denies nausea, vomiting, melena, vaginal bleeding, dysuria,
hematuria,
MM
is 18 years post-menopausal. She is
gravida=1, para=1. She has non-insulin
dependent diabetes mellitus and uses an oral hypoglycemic. She has mild osteoarthritis. 6 months ago her physician treated her for
‘low blood” with over-the-counter Geritol.
Physical Examination:
GENERAL/VITALS: MM is moderately obese who is alert and in
no distress. Vital signs (supine): B/P= 152/82 mm Hg, HR=92/min, Respirations=16/min, Temp=98.4 F.
HEENT: Bilateral cataracts. Pale conjunctiva.
CHEST: Large, pendulous breasts, no masses. Lungs clear to auscultation/percussion. Loud first heart sound. No murmurs.
ABDOMEN/RECTAL: Obese.
Soft, non-tender to light and
deep palpation. 12 cm healed scar in
RUQ. Percussion reveals slight
non-tender hepatomegaly. Normal bowel
sounds. Rectal exam reveals no masses. Stool is + for occult blood.
PELVIC: Normal external genitalia. Atrophic vaginal mucosa. No adnexal masses.
Laboratory evaluation: Hemoglobin=9.9 gm/dl, Hematocrit=30%, MCV=72, alkaline phosphatase= 167 IU/L, total bilirubin=1.8 mg/dl,
chest x-ray=nl, liver transaminases=pending,
liver
CT=ordered.
Discussion
Questions
1.
Define
all unknown terms in the protocol.
2.
What
is the major clinical problem (not the diagnosis)?
3.
Develop
a reasonable differential diagnosis for the patient’s constipation.
4. What is the likely diagnosis? Cite data from protocol to support your diagnosis.
5. What is the significance of the laboratory in this case?
6. What do you think the liver CT will show?
7.
What
type of anemia does this patient have?
Would you have expected this?
8. What would you have done 6 months ago when
the anemia was first discovered?