HELp mE DoCTORs

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Please DOCTORS .... I need your help ! !
Our doctor asked us to answer the questions & discuss the following case ... that doesn't mean I'm dependent, but I want to read some opinions...
coz this is my first exposure to a clinical case..


34 year old male patient who works in a bank presents to emergency room with two episodes of vomiting coffee ground material. The first episodes occurred spontaneously, there was no retching or repeated vomiting. The second episode occurred 2 hours later. He vomited around a half cup for each time. He felt dizzy & was about to fall down. There is no history of prior peptic ulcer disease ( PUD) & no history of jaundice. He has been taking ibuprofen for the last 14 days for painful shoulder following volleyball game.

Discussion points:
Is there a difference in the presentation between coffee ground & bright red blood .
How does age, sex & the presentation of coffee ground vomiting help you to formulate a differential diagnosis for this case .
How these information helped in formulated your differential diagnosis: " No repeated vomiting ", " no prior history of jaundice" ?
This patient has no prior history of PUD, does this rule out the diagnosis of PUD ?

What is the relation between ibuprofen & gastrointestinal bleeding ?
Why do you think this patient was dizzy & about to fall ?
Is there any further historical information you want to obtain by from this patient ?
you will examine this patient fully form head to toe, but what important physical sign you will be interested to know first ?
Is rectal examination is important in this case ?
Your management plan started with history & physical examination, now you are managing this patient medically, so what's your immediate goal of management ?

Please help me ..

 

[drmota]

are you serious. this thread needs to be moved to bangladesh.
-mota

 

[Southpawz]

Classic case of haematemesis.

 

[63768]

learnmed, i don't know if that's the true answer since i don't know anything about haematemesis but that's cool. why are we answering your questions again? should this not be preallo?

 

[Southpawz]

Yea, I don't think any premed can do this question. This question would be more suited in Allo.

Anyways, in no particular order and off the top of my head, here are some answers:

Anyways, it's black because the blood has come in contact with acid in the stomach. That's the difference between coffee ground vomit and bright red blood. Coffee ground blood usually suggests a smaller bleed.

Those drugs are NSAIDS = gastroduodenal erosion

Dizzy and about to fall = most likely the loss of blood

Don't need a rectal examination. (Unless something in the history tips you off to something wrong down there)

PUD cannot be ruled out.

And it's 3am here so im going to bed.

 

[doctorFred]

Please DOCTORS .... I'm really need your help ! !
Our doctor asked us to answer the questions & discuss the following cases ... that doesn't mean I'm dependable but I have to listen to the others opinions...
Please help me as fat as you can ... even you have an answer for one questions ...

Case 1 :
34 year old male patient who works in a bank presents to emergency room with two episodes of vomiting coffee ground material. The first episodes occurred spontaneously, there was no retching or repeated vomiting. The second episode occurred 2 hours later. He vomited around a half cup for each time. He felt dizzy & was about to fall down. There is no history of prior peptic ulcer disease ( PUD) & no history of jaundice. He has been taking ibuprofen for the last 14 days for painful shoulder following volleyball game.

Discussion points:
Is there a difference in the presentation between coffee ground & bright red blood .
How does age, sex & the presentation of coffee ground vomiting help you to formulate a differential diagnosis for this case .
How these information helped in formulated your differential diagnosis: " No repeated vomiting ", " no prior history of jaundice" ?
This patient has no prior history of PUD, does this rule out the diagnosis of PUD ?

What is the relation between ibuprofen & gastrointestinal bleeding ?
Why do you think this patient was dizzy & about to fall ?
Is there any further historical information you want to obtain by from this patient ?
you will examine this patient fully form head to toe, but what important physical sign you will be interested to know first ?
Is rectal examination is important in this case ?
Your management plan started with history & physical examination, now you are managing this patient medically, so what's your immediate goal of management ?

Please help me ..

 

[Uncle Izzy]

This is NOT classic hematemesis because it is not bright red blood vomiting.

No retching is important because it eliminates Mallory-Weiss tears.

Coffee Grounds= blood clots/digested blood, whereas bright red blood (BRB)= active bleeding. It also indicates that the blood has been there for a while and there is probably no active bleeding... at least not in the stomach or proximal duodenum.

You absolutely have to have his vitals. His BP may be low and his pulse high. Check his temp as well, although it will most likely be within normal limits.

The fact that he is vomiting blood suggests that the bleeding is proximal to the ligament of treitz... i.e. its in the GI tract, probably in the stomach but may also be in the 1st portion of the duodenum.

Rectal exam is absolutely necessary in this case and you have to do a guaiac as you would expect digested blood in the stool. If there is bright red blood in the stool, he could have a distal bleed as well. This is also imoportant because if he has digested blood (called melena.... tarry black stools) this would indicate that the bleed has been ongoing and slow and he has had time to pass digested blood.

The patient is dizzy because of blood loss... but dont forget he may also be severly dehydrated. Dont forget you differential here including neurologic, etc..

No history of PUD absolutely does not eliminate the possibility of PUD. It actually is at the top of my differential right now based on the fact that he is on a non specific NSAID(i.e. cox1 and cox2 inhibitor).

Further history should include environmental factors, alcohol use, history of PUD, family history of liver probs and other medical hx, trauma, social history, drug use. Past medical history is crucial. Other history hould include current meds which could cause bleeding.

No jaundice helps because it tells you that he probably doesnt have liver disease which causes back up in the portal circulation. When you have liver disease, you back up the portal venous system which causes esophageal varices (tender, very fragile, engorged veins in the distal esophagus, proximal stomach) which can easily rupture and cause HUGE blood loss. This is a medical emergency. In any case, your inital work up should include liver enzymes to see what his liver function is... you still need to include liver probs in your differential.

Immediate goal is to resuscitate the patient... Fluids immediately to replenish blood loss, especially if vitals are out of whack. Another major thing that needs to be done is a nasogastric tube... do a gastric lavage to see how much more is in there and to look for active bleeding. Otherwise, if he is still nauseated, you want to put the NG to suction. You can replace blood products as needed, but order a CBC first (platelet count, hemoglobin, hematocrit and WBC count). You also want to check for H. Pylori. You need a chem 7 as well (Na, K, Cl, bicarb, BUN, creatinine, glucose). A set of coags (PT, INR, PTT) will help you figure out his ability to clot blood. Also, while you are running IV fluids, you might as well give proton pump inhibitor to decrease acid levels in the stomach.

Once you are sure there are no active bleeds that you could further traumatize with an invasive procedure and the patient is stable with regards to blood loss and fluids, you can consider doing an upper GI study... scope him from ablove to visualize the stomach and proximal duodenum. If you see ulcers, then treat as appropriate... abx for H pylori, proton pump inhibitor or H2. For god's sake, no more NSAIDs unless you try a cox 2 specific, but we all know about the lawsuits with that (think VIOXX). If that is inconclusive, you can do a lower GI although it is likely to be very low yield. Another possibility is doing a CT with IV contrast to look for active bleeds. Another option for later is doing a full GI study with a camera capsule.

Good luck. If i was unclear, I'd be glad to clarify.

 

[Mr. Adventure]

Mine's still bigger than yours is... 😀

 

[fourthyear]

Do your own work - open a book and look this up.

Why are you posting your homework on this forum????

 

[Solideliquid]

Izzy-

That was a great post I agree with everything you said 100%.

Where is gastritis on your list of DDx? I would put it #2 below PUD.

 

[lattimer13]

Please DOCTORS .... I'm really need your help ! !
Our doctor asked us to answer the questions & discuss the following cases ... that doesn't mean I'm dependable but I have to listen to the others opinions...
Please help me as fat as you can ... even you have an answer for one questions ...

Case 1 :
34 year old male patient who works in a bank presents to emergency room with two episodes of vomiting coffee ground material. The first episodes occurred spontaneously, there was no retching or repeated vomiting. The second episode occurred 2 hours later. He vomited around a half cup for each time. He felt dizzy & was about to fall down. There is no history of prior peptic ulcer disease ( PUD) & no history of jaundice. He has been taking ibuprofen for the last 14 days for painful shoulder following volleyball game.

Discussion points:
Is there a difference in the presentation between coffee ground & bright red blood .
How does age, sex & the presentation of coffee ground vomiting help you to formulate a differential diagnosis for this case .
How these information helped in formulated your differential diagnosis: " No repeated vomiting ", " no prior history of jaundice" ?
This patient has no prior history of PUD, does this rule out the diagnosis of PUD ?

What is the relation between ibuprofen & gastrointestinal bleeding ?
Why do you think this patient was dizzy & about to fall ?
Is there any further historical information you want to obtain by from this patient ?
you will examine this patient fully form head to toe, but what important physical sign you will be interested to know first ?
Is rectal examination is important in this case ?
Your management plan started with history & physical examination, now you are managing this patient medically, so what's your immediate goal of management ?

Please help me ..

i can understand posting for others opinions if it is a zebra and/or you've tried to look it up on your own without success...but this is absurd...you'll never learn anything this way.

sounds like when you're in middle school and you copy your buddies homework on the schoolbus on the way to school because you're just too lazy to do it. 😉