miky
Forum Senior
Topics: 16
Posts: 99
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55 yo male
History:
heavy smoker (20 cigs/day),
acute MI 5 yrs ago;
takes Aspirin 81mg/day;
does not drink.
Comes to the ER after 3 bouts of severe blood vomiting. He is pale, dizzy and diaphoretic. One day ago he sustained a severe blunt chest trauma which he ignored. Mild chest pain, especially in the back unrelated to exercise, rest, food, body position, breathing and non-radiating.
Physical:
BP = 100/ 60 supine, 70 / 50 orthostatism
HR = 140
RR = 28
upper limb pulse - rapid but present
lower limb pulse - unrecordable (can't feel)
Chest: clear lungs, trachea in the middle, 2/6 systolic murmur heard at the apex
Abdomen: unremarkable
The rest of the physical exam is unremarkable.
Lab:
CXR: normal
SaO2 = 90 %
AXR: normal
A NG tube is inserted and shows some blood in the stomach.
Endoscopy is then ordered and shows no abnormalities of lower esophagus, stomach or duodenum.
The patient vomits blood in front of your eyes for the 4th time; the blood is red;
The most probable dx is  :
The next investigation is 8) :
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| mdwannabe
Forum Guru
Topics: 37
Posts: 1,133
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seems like a traumatic disecting anurism. low BP, high pulse, pulse differential, and syst murmur, however, why is the patient vomiting blood? Pulmonary artery anurism/rupture post trauma??? Possible. Can also be Pulmonary contusion with one of the larger branches of bronchial arteries rupture. Some blood in Stomach can be explained by swallowing. Large blood per oral, may be mostly hemoptysis with decreased SpO2 seems likely. In any case the CT of Chest is in order. TPatient is fairly stable...then to Sx.
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