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Mr Donaldson is a 47-year-old male who presents to the emergency department with a 12-hour history of vomiting bright red blood. He has had 4 episodes of emesis during this time span. He also complains of nausea, fatigue, and light-headedness. He had 1 episode of melena shortly before arrival. He denies abdominal pain, diarrhea, or fevers. He has a history of hypertension and chronic back pain secondary to a car accident. His medications include hydrochlorothiazide, amlodipine, and ibuprofen. He smokes 1 pack per day. He also drinks 6 to 8 beers per day, with more being consumed on the weekends and holidays. He has drunk this amount of alcohol for 22 years. On examination, he appears drowsy, with a blood pressure of 94/46 mm Hg, heart rate of 122 bpm, respiratory rate of 24 breaths/min, and oxygen saturation of 96% on room air. He is afebrile. His eyes are slightly icteric. His oral mucosa is slightly dry. Chest auscultation reveals clear lungs and a regular heart rhythm. Abdominal examination reveals mild distention and evidence of hepatomegaly. His rectal examination reveals heme-positive stool.

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Laboratory data show hemoglobin 9.8, hematocrit 29, and platelets 98,000. BUN is 28 and creatinine is 1.2. INR is 1.6. AST is 102 and ALT is 68.

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1. What is the most likely diagnosis?

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2. What is the initial goal of evaluation and patient care?

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3. What else is on the differential diagnosis?

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Answers

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This is a 47-year-old male with risk factors for GI bleeding (alcohol abuse and NSAID usage) who presents with several episodes of hematemesis. His vitals, physical examination, and laboratory data suggest volume loss and hemodynamic instability. He requires rapid evaluation and treatment, including volume resuscitation and workup for the cause of his bleeding.

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  1. The most likely diagnosis is bleeding from esophageal varices.

  2. The initial goals of his care revolve around volume resuscitation and hemodynamic stability with an urgent GI consult.

  3. The differential diagnosis includes peptic ulcer disease, esophagitis, gastric varices, and Mallory-Weis tear.

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Analysis: This case represents the approach to a patient with an upper GI bleed with a focus on initial assessment and resuscitation, as well as a discussion of the differential diagnoses.

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Upper GI Bleed

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Diagnosis

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Historical Clues
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A focused history should revolve around such questions as history of length of time and progression of bleeding, associated symptoms (nausea, retching, abdominal pain), prior history of GI bleeding, and medication usage.

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Physical Clues
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Vital signs revealing hypotension, tachycardia, tachypnea, and hypoxia can help determine the degree of blood loss. Other physical examination findings to look for include dry mucus membranes, poor skin turgor, and evidence of chronic liver disease (jaundice, ...

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