This is our 1st case in a case series exploring the care of patients with GI related illnesses in the Emergency Department. Similar to our "Out on a Limb" and "Sepsis Smackdown" case series, the case presented is followed by a series of questions, with a discussion in the comment section facilitated by the post authors. In approximately 1 month, the authors of the post will conduct a combined simulation/small group session reinforcing the learning points from the posts during Grand Rounds. Around this time, they will also curate the comments from the discussion and publish a post highlighting these learning points. Looking forward to a great discussion!
Case by Jessica Nelson, MD
It’s late on a Saturday night and you are moonlighting as the single provider at a community hospital about 15 minutes from UC. You’re trying to disposition five current patients when a new patient is brought in by EMS with a complaint of vomiting blood. The patient smells of alcohol and states that he drinks daily, though he may have “overdone it” the last 2-3 days since he has had friends in town. He is 48 years old and denies any past medical history. He agrees with your records showing that he has not seen a doctor in more than 5 years. He denies taking any medications and does not have any allergies. His initial vital signs are: Temp 98.1°F, BP 105/45, HR 125, RR 24, O2 saturation 98% on room air. Your exam reveals the following abnormalities: dry mucous membranes, tachycardia, a diffusely tender abdomen, and melena on rectal exam. Labs are significant for:
- CBC: wbc 13.1, hemoglobin 8.9, platelets 120
- Basic metabolic panel: Na+ 127, Cl- 90, K+ 4.5, CO2 10, BUN 56, Cr 1.7, Glu 230,
- VBG: 7.15/30/-10 Lactate: 11.7
- Hepatic panel: Bili 4.5, Direct bili 1.2, AST 894, ALT 560, Alk Phos 90, Albumin 2.4
- Lipase: 124
- INR: 1.5
When responding you need only respond to 1 or 2 questions (leave some fodder for others!) and please begin your response with Q1, Q2, etc, denoting to which question you are responding.