GI Tuesday Conference

Identifying Data

58/F

Separated, 2 husbands

5 children

Housewife

From Caloocan
Chief Complaint

Hematemesis
History of Present Illness

Sept 3, 2014 previous admission

Painless hematemesis (~ 1 L)

Melena, unquantified

With gen. weakness and dizziness

No LOC/seizures

Admitted for 2 days

History of Present Illness

Patient advised EGD but refused

DAMA

No BT done

Interim, resumed normal activities

No recurrence of bleeding
History of Present Illness

1 day PTA

Painless hematemesis

50 mL/ep x 2 eps

Melena ~ 200 mL total

With dizziness/lightheadedness

Admission
Review of Systems

General: no fatigue, loss of appetite, no weight loss/gain

HEENT: no blurring of vision, no eye redness, no discharge,

no hearing loss, tinnitus, vertigo, no nasal discharge, no
throat pain, no hoarseness, no gum bleeding or epistaxis

Chest: no cough, colds, hemoptysis, shortness of breath

CVS: no chest pain, palpitations, PND, orthopnea

Review of Systems

GI: no vomiting, no change in bowel movement

GU: no flank pain, dysuria, hematuria

Neuro: no seizure, LOC, no focal weakness, no slurring of

speech, no numbness or tremors

MSK: no myalgia, muscle weakness, masses, back pain

Derma: no rashes or other skin lesions noted

Past Medical History

No DM

No HPN

No BA

No PTB

No allergies

(+) s/p cholecystectomy at 42 y/o c/o Jose Reyes

Family Medical History

No DM

(+) HPN and MI father

(+) BA and stroke mother

No PTB

No Hepatitis

No similar illness
Personal Social History

15 pack year smoker

Previous heavy alcoholic

(From 25-33 y/o, drinks 1x/wk, can finish 1 case of beer by

herself per session)

Denies illicit drug use

Physical Examination

BP 100/70 HR 75 RR 14 T afebrile

Awake, coherent, not in distress, speaks in sentences

Anicteric sclerae, pink conjunctivae, no anterior neck mass,

no neck vein engorgement, no lymphadenopathy

Equal chest expansion, no spider angiomata, clear breath

sounds, no rales/wheezes

Adynamic precordium, distinct heart sounds, normal rate

regular rhythm, no murmurs
Physical Examination

Flabby, (+) 10 cm cholecystectomy scar, nontender, no

hepatosplenomegaly, no masses palpated

Full equal pulses, pink nail beds, no cyanosis/jaundice or

edema

DRE: (+) external hemorrhoids, no anal fissures, no skin tags,

good sphincter tone, intact rectal vault, no masses, no blood
or melena per examining finger
Labs/Workup

CBC

WBC 12.3

Hgb 105

Hct 0.320

Plt 152

Neut 77%

Lym 20%
Labs/Workup

BUN 11.1

Crea 55.2

Na 137.5

K 4.06

Cl 105.6
Labs/Workup

ECG: Sinus rhythm, within normal limits

PT 14.3/63.6%/1.27 INR/13.1

PTT 24.2/28.0