A Case Report

:
Upper Gastrointestinal Bleeding in a 58 y/o Alcoholic Patient with Stigmata of Chronic Liver Disease
JI Joshua Balunsay-Camaing JI Prima Donna Estorninos JI Allen Jurado JI Tara Angela Krysteena Oliveros-Dela Cruz JI Laura Angela Palisoc-Saberola JI Elizabeth Jeremmie Reyes PGI John Paul Benitez PGI Joyce David PGI Justin Melissa Dureza PGI Juliet Kristine Evangelista PGI Julie Gayon

LEARNING OBJECTIVES
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.

GENERAL DATA
• • • • • • 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

CHIEF COMPLAINT Melena .

HISTORY OF PRESENT ILLNESS • • Abdominal enlargement Abdominal fullness 1 year PTA • • Consult Ultrasound & Endoscopy done Lost to follow-up • .

Left was done • Discharged .HISTORY OF PRESENT ILLNESS 6 months PTA • • • • • Previous symptoms Jaundice Flank pain Consult/Admitted Shockwave Lithotripsy.

HISTORY OF PRESENT ILLNESS 5 months PTA • • • • • • Regular follow-up Dyspnea Admitted COPD Liver Cirrhosis Discharged .

jaundice.HISTORY OF PRESENT ILLNESS 4 months PTA • Regular follow-up • Abdominal enlargement. & 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 Few hours PTA • Melena • Consult • ADMISSION .

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 .

FAMILY HISTORY (+) Hypertension – paternal .

PERSONAL & SOCIAL 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 .

(-) ear discharge. (-) hearing loss. (-) colds . (-) change in color of moles HEENT (-) headache. no blurring of vision (-) tinnitus. (-) dizziness. (+) easy fatigability (-) rashes.REVIEW OF SYSTEMS General Skin (+) weight gain. (+) poor appetite.

(-) cough Heart (+) orthopnea.REVIEW OF SYSTEMS Chest & Lungs (-) hemoptysis. (-) constipation. (+) dyspnea. (-) diarrhea. (+) paroxysmal nocturnal dyspnea. (-) hematochezia. (-) dysphagia. (-) palpitations Abdomen (-) abdominal pain. (-) vomiting .

(-) loss of consciousness. (-) dysuria Neurologic (-) diaphoresis. (-) hematuria. (-) nocturia.REVIEW OF SYSTEMS Genitourinary (-) polydipsia. (-)sensorial changes . (-) seizures. (-) polyphagia. (-) polyuria.

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

9C 77 bpm 22/rpm 0/10 .PHYSICAL EXAMINATION Vital Signs: BP: Temperature: Heart Rate: Respiratory Rate: Pain Scale: 110/70 36.

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

. no area of tenderness.PHYSICAL EXAMINATION HEENT: Head Round-shaped. no lesions in the scalp. with no lesions. symmetrical with abundant. symmetrical face. Facial skin color is icteric with no areas of hyper-or hypopigmentations. equally distributed hair.

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

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

pink mucosa.PHYSICAL EXAMINATION HEENT: Nose (+) alar flaring. septum is midline . (-) deformity. obstruction. symmetrical.

(+) dental caries and poor dentition. (-) canker sores. roof of the mouth is hard.PHYSICAL EXAMINATION HEENT: Throat Pale and dry lips. No tonsilopharyngeal congestion . whitish tongue. No sores on the floor of the mouth.

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

(+) retractions. (-) crackles. (-) lagging (-) masses. wheeze or rhonchi (-) bronchophony. egophony and whispered pectoriloquy . tactile fremitus is equal in both lungs. Resonant both in anterior and posterior Vesicular breath sounds. (+) gynecomastia. (-) tenderness. (-) cyanosis (-) audible wheezing or stridor (-) contraction of the accessory muscles Transverse diameter is much wider than the AP diameter Symmetric chest expansion.PHYSICAL EXAMINATION Chest/Lungs • • • • • • • • • Symmetrical.

at the base. (-) visible pulsations. at the apex S1>S2 • (-) murmurs .PHYSICAL EXAMINATION Heart • Adynamic precordium. S2>S1. lesions. Size is about 2 cm and tapping • Crisp S1 and S2. left MCL. (-) precordial bulging • JVP is 3 cm above suprasternal angle • Apex beat is palpable in the 5th ICS midclavicular line. (-) scars. apex beat is at 5th ICS. signs of trauma and previous surgery.

rest of the abdomen is tympanitic • (+) shifting dullness. and iliac bruit. Abdominal girth=42 inches • (+) normoactive bowel sounds. shiny & tensed. lumbar. icteric skin.PHYSICAL EXAMINATION Abdomen: • Abdomen is globular. liver span=8.0 cm Right MCL • Traube’s space is dull. (-) abdominal. with visible dilated superficial abdominal veins. (-) friction rubs • (-) palpable masses • Liver edge is knobby. (+) fluid wave test . (+) rebound tenderness on Left Upper Quadrant. everted umbilicus.

PHYSICAL EXAMINATION Peripheral Vascular • • • • • • Extremities are warm (+) bipedal edema No varicosities or stasis changes Calves are supple and nontender (-) femoral or abdominal bruits Brachial. popliteal. radial. dorsalis pedis (DP). femoral. and posterior tibial (PT) pulses are 2+ and symmetric .

PHYSICAL EXAMINATION Back and Spines • Symmetrical • (-) spasm and tenderness of the paravertebral and back muscles .

scars • (-) tenderness upon firm pressure along the joint margins.PHYSICAL EXAMINATION Extremities • Paired joints are symmetrical • (+) bipedal edema • (-) evidence of redness. skin rash. subcutaneous nodules. and over tendons and ligaments • Full range of motion . cysts.

no apraxia .PHYSICAL EXAMINATION Neurological: CEREBRAL • Alert but appears anxious • Speaks in soft tone • Thought is coherent and oriented to person. place and time • (-) aphasia. no agnosia. 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.

VI V VII VIII IX.PHYSICAL EXAMINATION Neurological: Cranial Nerves I II III. X XI XII intact sense of smell pupils equally reactive to light and are 2-3 mm constricted intact extraocular muscles intact corneal reflex (-) facial asymmetry intact hearing intact gag reflex can shrug shoulders tongue is at midline . IV.

good muscle tone Motor Strength Right upper extremities: 5/5 Left upper extremities: 5/5 Right lower extremities: 3/5 Left lower extremities: 3/5 Sensory: Light touch.PHYSICAL EXAMINATION Neurological: Motor (-) atrophy of the muscles of both upper and lower extremities. and stereognosis are 100% intact throughout the body . vibration and sharp or dull pain sensation.

PHYSICAL EXAMINATION Neurological: Cerebellar Rapid alternating movements. finger-to-nose. heelto-shin test intact (-) pronator drift Tandem walking revealed no ataxia (-) Babinski reflex .

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

GASTROINTESTINAL TRACT
pH is acidic Hematemesis Melena hematochezia

Frothy pH is basic Preceded by cough Evidence of epistaxis or gum bleeding Swallowed and appear as melena or occult blood in stool

from proximal colon .UGIB VS LGIB  UPPER GI TRACT  LOWER GI TRACT Hematemesis Melena Hematochezia (massive bleeding >1000ml) Increased Transit Time Hematochezia Melena if with altered bowel function (constipation) or obstruction.

p 1969. USA: 2008. 17th Edition. .. McGraw-Hill Companies.ABOUT ALCOHOLISM • 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. Inc.

Inc. p 1969. 17th Edition. .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.. USA: 2008. McGraw-Hill Companies.

11th Edition. Inc.. . each) = 6 oz. of fortified wine = 8 bottles of beer (12 oz. (44ml) of ethanol in 77-kg person = 12 oz. USA: 2010. p 421-422. 8th Edition. Elsevier. Katzung Basic and Clinical Pharmacology. USA: 2008. p 365.. McGraw-Hill Companies. Inc. of 100-proof whiskey • Habitual drinkers – can tolerate up to 700mg/dL Robbins and Cotran Pathologic Basis of Disease.ABOUT ALCOHOLISM • Blood Alcohol Concentration of 80-100 mg/dL – legal definition for driving under influence of alcohol • 3 oz.

Elsevier. Inc. respiratory arrest Robbins and Cotran Pathologic Basis of Disease. p 421-422. McGraw-Hill Companies. . 8th Edition.ABOUT ALCOHOLISM • 100-200 mg/dL – impaired motor function. USA: 2010. USA: 2008. ataxia • 200-300 mg/dL – emesis. stupor • 300-400 mg/dL – coma • >500 mg/dL – death. p 365. Inc.. slurred speech. Katzung Basic and Clinical Pharmacology. 11th Edition..

STIGMATA OF LIVER CIRRHOSIS .

40-80g/day produces fatty liver. Hepatitis C Infection .PATHOPHYSIOLOGY Risk Factors for Alcoholic Liver Disease 1. Quantity – In men. 160g/day in 10-20 years causes hepatitis or cirrhosis 2. Gender – Women>men 3.

Malnutrition – Obesity and fatty liver from effect of CHO on transcriptional control of lipid synthesis and transport . cytochrome p4502E1. Genetics – genetic polymorphisms (alcohol dehydrogenase.PATHOPHYSIOLOGY Risk Factors for Alcoholic Liver Disease 4. and those associated with alcoholism) 5.

PATHOPHYSIOLOGY Results: 1. Acetaldehyde adducts formation 2. Increase NADH:NAD+ formation . Increase ROS formation 3.

PATHOPHYSIOLOGY Chronic Alcoholism ↑ reduced NADH Impaired assembly and secretion of lipoproteins ↑ peripheral catabolism of fat ↑ lipid biosynthesis ↑ FA uptake & ↓ FA oxidation Gross accumulation of fat in liver cells .

PATHOPHYSIOLOGY Chronic Alcoholism Decreased intrahepatic GSH levels Induction of Cytochrome P-450 Oxidative injury to liver Production of ROS Interfere with specific enzyme activities Alter hepatocellular function (microtubular formation & protein trafficking) Kupffer cell activation React with cellular proteins forming protein-acetaldehyde adducts .

PMN infiltrate and fibrosis in the perivenular and perisinusoidal space) Liver fibrosis and scarring Liver contracts and shrinks Decreased liver function Obstruction of portal circulation Portal Hypertension (>5 mmHg HVPG) .PATHOPHYSIOLOGY Continuing alcohol ingestion Progressive hepatocyte injury (ballooning degeneration. spotty necrosis.

PATHOPHYSIOLOGY OF ESOPHAGEAL VARICES Deranged (vascular) architecture Vasoconstrictor (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 Hypoalbuminemia & ↓ Plasma oncotic pressure Splanchnic vasodilation ↑ Splanchnic pressure Lymph formation Formation of peripheral edema & ascites Arterial underfilling Activation of vasoconstrictors and antinatriuretic factors Sodium retention Plasma volume expansion .

PATHOPHYSIOLOGY Portal Hypertension Direct toxic effect of alcohol Congestive splenomegaly Diversion of portal blood to systemic circulation Testicular atrophy Hypersplenism Venous collateral shunt Hormonal abnormalities LUQ pain Thrombocytopenia Caput medussae Digital Clubbing Gynecomastia Decreased body hair Spider angiomatas Palmar Erythema .

PATHOPHYSIOLOGY Decreased Liver Function ↓ protein production ↓Clotting factors Bleeding tendencies ↓ Bilirubin uptake and storage Hyperbilirubinemia Hypoalbuminemia Terry’s Nails Muehrcke's lines Anemia Icteric sclera Jaundice .

PATHOPHYSIOLOGY Vascular Shunting Impaired removal of Gut-derived neurotoxins Decreased Hepatic Mass ↑Ammonia levels Altered mental status Asterixis Coma Death .

PATHOPHYSIOLOGY .

Mallory-weiss Tears 3. Erosive Gastritis . Gastroduodenal Ulcer 2. Gastric/Duodenal Varices (Portal Hypertensive Gastropathy) 1. Bleeding Esophageal Varices 2.CAUSES OF UGIB IN THE SETTING OF ALCOHOLIC LIVER DISEASE 1.

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 .

pylori infection and chronic NSAID intake .CAUSES OF UGIB IN THE SETTING OF ALCOHOLIC LIVER DISEASE Gastroduodenal Ulcer • Rule In: • (+) melena • Rule Out: • More commonly associated with H.

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) .

ADMITTING IMPRESSION UPPER GASTROINTESTINAL BLEEDING secondary to Bleeding Esophageal Varices .

CBG q6. K. Crea. I&O qshift • IVF D5NM 1L X 60cc/hr • NPO except medications • CBC.APPROACH TO PATIENT AT THE EMERGENCY ROOM • Hematemesis • Melena • VS: BP120/70 • PR=77 bpm • RR=22 rpm • T=36. ECG. Na.9ºC • Chronically illlooking UGIB secondary to Bleeding Esophageal Varices • Admit to MMW • VS q2. CXR • Pantoprazole drip at 6mg/hr • Lactulose syrup 30cc BID • Standby 2U PRBC • For EGD once stable .

19 x 10 ^12/L 12.32 – 0.42 – 0.50 4.7 fl 38 pg 0.36 .01 Decreased 115.5 – 18.20 13.33 0.56 0.3 x 10^9/L 0.5 – 11 0.10 g/dL REFERENCE 4.LABORATORY RESULTS COMPONENT RBC Hemoglobin RESULT 3.77 0.37 12.34 Monocytes Platelet count MCV MCH MCHC 0.0 Hematocrit WBC Segmenters Lymphocytes 0.04 150 – 400 80 – 96 27 – 31 0.20 0.6 – 6.

89 mg/dl 132.20 135-148 3.5 mmol/L Clinical Chemistry Creatinine Sodium Potassium RESULT 0.1 mmol/L 2.60-1.3 .5-5.74 mmol/L REFEREN CE 0.LABORATORY RESULTS CBG = 7.

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 .

APPROACH TO PATIENT WITH GI BLEEDING HISTORY • Weakness. syncope associated with hematemesis and melena • A brisk UGIB manifests as hematochezia • History of dyspepsia. ulcer disease. dizziness. early satiety. and NSAID or aspirin use • Prior history of ulcers .

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 • In a more subacute phase.

ascites. splenomegaly. and asterixis • Signs of tumor: nodular liver. gynecomastia. an abdominal mass. pedal edema. and enlarged and firm lymph nodes . increased luneals.APPROACH TO PATIENT WITH GI BLEEDING PHYSICAL EXAMINATION 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.

COURSE IN THE WARD DAY OF ADMISSION • Difficulty of Breathing • Melena • VS: BP=100/70 • PR=100 bpm • RR=23rpm • T=36.0ºC • Chronically illlooking UGIB secondary to BEV • KCl drip at 5 mEq/hr • Furosemide 20mg/IV .

COURSE IN THE WARD 1ST DAY OF HOSPITALIZATION • Difficulty of Breathing • Hematemesis • Melena • • • • • VS: BP=90/60 PR=120 bpm RR=26rpm T=37. q8 X 3 days • Repeat CBC with APC .3ºC Chronically illlooking UGIB secondary to BEV • Refused transfer to MICU-CD • For transfusion of 1 unit PRBC • Transfer to MICUCD • Transfuse 4 U FFP • Somatostatin drip PNSS 250cc + 3mg X 12hrs • Somatostatin 250 mcg/IV • Lactulose 30cc TID • Vit K 10mg/amp.

9 fl 38 pg 0.5 – 18.34 Monocytes Platelet count MCV MCH MCHC 0.0 Hematocrit WBC Segmenters Lymphocytes 0.20 g/dL REFERENCE 4.03 Reduced 114.LABORATORY RESULTS COMPONENT RBC Hemoglobin RESULT 3.56 0.42 – 0.6 – 6.37 12.21 x 10 ^12/L 12.36 .32 – 0.09 0.5 – 11 0.50 4.34x 10^9/L 0.20 13.33 0.88 0.04 150 – 400 80 – 96 27 – 31 0.

7 secs (12-14 sec) PA = 36.LABORATORY RESULTS PT = 37.3) PTT = 40.9 secs INR = 3.7 secs (Control 29.9% (100%) Control: 13.0-1.5 secs) .95 (RV 1.

COURSE IN THE WARD 2ND DAY OF HOSPITALIZATION • Hematemesis • Hematochezia 2x • (+) easy fatigability • VS: BP=119/71 • PR=137 bpm • RR=36rpm • T=36.8ºC • Awake. weaklooking UGIB secondary to BEV • Refused Intubation • Repeat PTPA after last dose of Vit K • Continue KCl drip • Levofloxacin 500mg/IV OD • For gastroscopy • Standby 2 units PRBC .

42 – 0.32 – 0.5 – 18.3 pg 0.LABORATORY RESULTS COMPONENT RBC Hemoglobin RESULT 2.6 – 6.2 x 10 ^12/L 8.50 4.26 17.3x 10^9/L 0.5 – 11 0.08 0.20 13.34 Monocytes Platelet count MCV MCH MCHC 0.0 Hematocrit WBC Segmenters Lymphocytes 0.36 .4 g/dL REFERENCE 4.04 150 – 400 80 – 96 27 – 31 0.02 77 116 fl 38.56 0.90 0.33 0.

3 secs INR = 2.60 mmol/L PT = 29.9 secs (12-14 sec) PA = 49.0-1.LABORATORY RESULTS Serum Potassium = 2.99 (RV 1.1% (100%) Control: 13.3) .

3 mmol/L 7.LABORATORY RESULTS DATE & TIME 6/22/12 – 7:13 pm 6/22/12 – 12:00 am 6/23/12 – 06:00 am 6/23/12 – 12:00 pm 6/22/12 – 06:00 pm 6/24/12 – 12:00 am 6/24/12 – 06:00 am CBG RESULTS 7.5 mmol/L 7.3 mmol/L 7.1 mmol/L 6/24/12 – 12:00 pm 6/24/12 – 06:00 pm 6/25/12 – 12:00 am 6/25/12 – 06:00 am 7.7 mmol/L 5.3 mmol/L .9 mmol/L 6.2 mmol/L 8.4 mmol/L 5.8 mmol/L 7.5 mmol/L 7.

COURSE IN THE WARD 3RD DAY OF HOSPITALIZATION • Difficulty of Breathing • Refused Intubation • VS: BP=120/80 • PR=170 bpm • RR=27rpm • T=37. ½ ampule • O2 at 10LPM via face mask • Furosemide 20mg/IV • For ABG’s now . OD • Digoxn 0.25mg/IV.0ºC • O2 sat=70% • (+) Crackles both lung fields UGIB secondary to BEV • Hold gastroscopy • Lactulose 30cc q6 • Hold CBG monitoring • Spironolactone 25mg/tab.

COURSE IN THE WARD 4TH DAY OF HOSPITALIZATION • Difficulty of Breathing • Refused Intubation • VS: BP=120/80 • PR=170 bpm • RR=27rpm • T=37.0ºC • O2 sat=5070% • (+) Crackles • CLINICALLY DEAD at 3:43am UGIB secondary to BEV • Bicarbonate 150 mEqs slow IV push • Do rhythm strip • Post-mortem Care .

FINAL DIAGNOSIS .

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