indidoc1
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31.
Paramedics bring in a 62-year-old man who called 911 after waking in a pool of bloody vomit. He reports being on an alcoholic binge, and does not remember the events that preceded his vomiting. He has no abdominal pain and no prior history of gastrointestinal bleeding. He has a blood pressure of 120/90 mm Hg supine, 100/78 mm Hg standing; pulse of 112/min; and respirations of 20/min. Physical examination reveals a disheveled man with pale conjunctiva and temporal wasting. Spider angiomas are seen on his chest. Abdominal examination reveals hepatosplenomegaly, but no tenderness or guarding. Rectal examination reveals melenic stool that is positive for blood using a standard occult blood test. Nasogastric aspiration reveals brownish-black “coffee-ground” material that clears with normal saline lavage. A stat complete blood count reveals a hematocrit of 29%. Intravenous access is obtained and a fluid bolus is given. Which of the following is the most appropriate next step in management?
A. Begin intravenous propranolol
B. Begin immediate therapy with proton pump inhibitors
C. Perform a stat endoscopy
D. Send blood for type and cross-match
E. Start a vasopressin infusion
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| darkhorse
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D.
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| neuroblastoma
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C
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| cool doctor
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its a nice question with most of the choices r correct
I will choose D
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| cool doctor
Forum Junior
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Hey neuroblastoma
we didnt agree on any of the 5 questions
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| alzheimer
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I will go for A but not sure......bleeding has stopped..u have to prevent another bleeding..Am I wrong?
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| me007
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d bcs of hematocrit
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| Vietnamese
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D- As for massive bleeding of GI track, management is very important first, not diagnosis.
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| doyoudig
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C. Perform a stat endoscopy -- stop the bleeding -- diagnostic n therapeutic
vasopressin will not do much in a pt with such large volume hematemesis
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| tamerbashir
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C
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| indidoc1
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The correct answer is D. This patient has evidence of liver disease and of upper gastrointestinal bleed. The first course of action is to stabilize the patient. His blood should be typed and cross-matched immediately so as to be ready in case of rebleed.
Propranolol (choice A) can be used to reduce the risk of bleeding from portal hypertension by relaxing vascular tone. However, it has no use in an acute bleed.
Proton pump inhibitor therapy (choice B) and vasopressin (choice E) can be useful once the etiology of the bleed is determined. However, this patient is currently orthostatic, anemic, and at risk of rebleeding, and needs to have blood ready for him. The etiology of the bleed can be determined with endoscopy (choice C). However, this patient needs to be stabilized first.
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