Assignment: Patient J.W. a 65yr male by to the Emergency Room after several episodes of vomiting and confusion. The patients wife and mother are in the room and will respond to your questions since he is confused and incoherent

Assignment: Patient J.W. a 65yr male by to the Emergency Room after several episodes of vomiting and confusion. The patients wife and mother are in the room and will respond to your questions since he is confused and incoherent

Assignment: Patient J.W. a 65yr male by to the Emergency Room after several episodes of vomiting and confusion. The patients wife and mother are in the room and will respond to your questions since he is confused and incoherent

Subjective

Patient J.W. a 65yr male by to the Emergency Room after several episodes of vomiting and confusion. The patient’s wife and mother are in the room and will respond to your questions since he is confused and incoherent.

Chief Complaint:  Vomiting Blood, and Confusion

History of Present Illness: Wife states (We brought John to the hospital because he has been vomiting blood and feeling weak and confused.”

The confusion and weakness last for 2-5 days each time. The actual episodes happen every 2-3 months and it’s been this way for a year.”

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Past Medical History: 

Mononucleosis

HTN

Past Surgical History: 

N/A

Medications:

 Propranolol

Allergies:

Penicillin (Rash) No environmental allergies

Immunizations: 

UTD

Family History: 

Family has a history of breast cancer, leukemia, diabetes, and high blood pressure. Our two children are alive and well.”

“Social History/Risk Factors:

Occasional Drinker

Former Smoker

Review of Systems:

General: (+) fevers, (-) chills, (+) unintentional weight loss/gain, (+) changes in appetite, (+) changes in physical ability as per PHI, (+) fatigue, (-) malaise, (-) occasional night sweats as per HPI

Head: (-) headache, (-) dizziness, (-) sinus pressure (frontal and maxillary).

Eyes: (-) changes in vision, (-) blurred vision, (-) double vision, (-) redness, (-) redness.

Scleral icterus is present

Ears: (-) changes or difficulty in hearing, (-) ear pain, (-) drainage, (-) vertigo.

Nose: (-) difficulty smelling, (-) runny nose, (-) congestion, (-) epistaxis.

Mouth/Throat: (-) problems swallowing, (-) difficulty eating/chewing foods, (-) sores or lesions, (+) dentures. Last dental exam: unknown.

Neck: (-) stiffness, (-) pain.

Respiratory: (-) difficulty breathing, (-) shortness of breath, (-) cough, (-) dyspnea, (-) wheezing, all (-) as mentioned in HPI

Cardiovascular: (-) chest pain, (-) abnormal heartbeats, (-) skipped beats, (-) fluttering.

GI: (+) nausea/vomiting, (-) heartburn, (-) acid reflux, (-) pain with defecation, (-) rectal bleeding, (-) hemorrhoids. Bowel movement: (+) constipation, (-) diarrhea.

GU: (-) difficult urination, (-) painful urination, (-) urinary frequency.

Musculoskeletal: (-) pain joints, (-) problems with range of motion, (-) stiffness, (-) backaches.

Neurological: (+) weakness, (-) dizziness, (-) blurred vision, (+) unsteady gait, (-) changes in memory, (-) changes in mood.

Psychiatric: (-) depression, (-) anxiety, (-) Angry, (-) sleep disturbances, (-) nervousness, (-) suicidal ideation, (-) suicidal attempts.

Skin: (+) Nail changes, (-) rashes, (-) ulcer, (-) photosensitivity

Endocrine: (+) weight loss or weight gain, (-) excessive sweating, (-) hair thinning/loss, (-) hot or cold intolerance, (-) excessive thirst.

Hem/Lymph: (-) bruising or redness, (-) pain, (-) enlargement

Objective

Vital Signs: BP 110/70 mm Hg, Temp 99.2 F, Resp 16, HR 84, O2 sat 97%.

Height: 5’10” (178.2cm) Weight: 150lbs. (68kg)

General The patient appears lethargic and is lying motionless. He does appear to be in ill, but his respiration is shallow, but not distress

Neurological: Does not seem to follow commands

Head: Normocephalic, atraumatic. Hair distribution is full; hair is thick, with good luster.

Eyes: PERRLA. Eyes are symmetric in size, shape, color, and position. No scars, erythema, or growths are noted on lid or conjunctiva. Cornea is clear; pupil is round, equal, and black. Conjunctiva is moist and without discharge. No nystagmus is seen. Scleral icterus is present

Ears: Auricles are symmetric, normally placed, and without deformities; no area of tenderness is noted. No ear lobe creases are present. Right and left ear canals are clear; the drums are intact, with a bright cone of light in the pars tensa. The malleus is visible through the drum.

Nose: The patient’s nose is symmetric. Nasal mucosa is pink and moist, with a small amount of clear discharge; the septum is midline and without polyps slightly red in color; the turbinate’s are pink and moist with a clear passage between them. Maxillary and frontal sinuses transilluminate.

Mouth/Throat: Twenty-six teeth are present, several in both jaws having filled cavities, and no active caries are noted; teeth are well-aligned, and occlusion is symmetric with slight overbite. Gums are pale red and meet enamel margins of the teeth.
.Lips appear normal without ulcers or cracking. Buccal mucosa is pink, dry, and without ulcers or nodules. Hard palate is intact, uvula is midline and moves symmetrically. Tongue appears normal without coating. Pharynx and tonsils appear normal without exudate.

. Neck: The hyoid bone, thyroid, cricoid cartilages, and trachea are symmetric, in the midline, and mobile. Internal jugular pulses are noted to 7 cm above the sternal angle with the patient’s torso barely elevated.

Lymph Nodes: No subcutaneous nodules noted on palpation

Cardiovascular: First and second heart sounds are normal.

Respiratory: Breath sounds are readily heard throughout the lungs; are symmetric and vesicular, with inspiration being longer than expiration. Percussion note is resonant, relatively loud, low pitched, of long duration. Diaphragmatic excursion is 6 cm by percussion and is symmetric. Percussion of the costovertebral angle did not elicit any discomfort.

GI: Symmetrical without local bulges. On auscultation, clicks and gurgles are heard 10 to 15 times per minute and there are occasional borborygmi; no hums, bruits or friction rubs are heard. Abdomen is soft, nontender, and without masses.

There is no tenderness on light or deep palpation. The spleen is palpable and extends 3 finger breadths below the left costal margin. There is no referred pain or rebound tenderness.

Liver dullness is 6 cm. in the midsternal line and 9 cm. in the right midclavicular line; the area of dullness descends 3 cm. on inspiration.

Musculoskeletal: Active and passive range of motion is full. Full range of movement is possible.

Skin: Intact on inspection. No scars or rashes noted

Psychiatric (affect, mood): Affect and mood appropriate.

 

 

Diagnostic results:

WBC	17,600/mm3
RBC	3.21 m/mm3
Hemoglobin	10.1 g/dL
Hematocrit	31.2%
MCV	100 fL
MCH	32.0 pg
MCHC	31.8%
Platelets	97,000/mm3
Bands	2% WBC count
Neutrophils	72%% WBC count
Lymphocytes	22% WBC count
Eosinophils	1% WBC count
Monocytes	2% WBC count
Basophils	1% WBC count
Nucleated Red Blood Cells	1 nucleated red cell
Sodium, Na (Blood) 137 mEq/L Potassium, K (Blood) 2.3 mEq/L Chloride, Cl (Blood) 99 mEq/L Carbon Dioxide Content, CO2 29 mEq/L Phosphorus, P (Blood) 3.1 mg/dL Glucose, Random 149 mg/dL BUN 6 mg/dL Creatinine (Blood) 1.2 mg/dL Protein, Albumin 2.0 g/dL Protein, Total 7.0 g/dL
Specific Gravity 1.003 pH 5.0 Protein negative Bilirubin 2+ Glucose negative Ketones negative Occult Blood negative RBCs 0/HPF WBCs 0/HPF Bacteria negative on a spun specimen Crystals none seen Casts none Nitrates negative Urobilinogen negative
Occult Blood (Guaiac) Positive
Bilirubin (Blood) Total: 4.2 mg/dL   Alkaline Phosphatase 399 U/L Lactic Dehydrogenase (LDH) 264 U/L AST (SGOT) 338 U/L ALT (SGPT) 113 U/L Prothrombin Time (PT) 19.4 seconds (control 13.4 seconds) Partial Thromboplastin Time (PTT) 33.4 seconds (control 32.4 seconds) Thyroid-Stimulating Hormone (TSH) 2.3 mU/L Fibrinogen 425 mg/dL Hemoglobin A1c (HbA1C) 6.8% Abdomen (Ultrasound) No stones are noted in the gallbladder. There is no dilatation of the intra or extra hepatic bile ducts. The kidneys and liver are unremarkable. The head of the pancreas is poorly seen but no mass lesion or evidence of biliary obstruction is noted. There is splenomegaly. Epstein-Barr Virus titer Within normal limits. Cytomegalovirus (CMV) Antibody Test IgM: negative; IgG: 2 AU/mL Mono-Spot Test Negative Erythrocyte Sedimentation Rate (ESR) 13 mm/hour Abdomen (CT scan) and MRI Enlarged spleen.   Esophagogastroduodenoscopy (EGD) Esophageal varices and scattered coffee ground blood in stomach.

Assessment

Differential Diagnosis

1, GI Bleed

2, Cirrhosis

3, Esophageal varices

4, Splenomegaly

5, Hepatitis

Working Diagnosis

1, GI Bleed

2, Cirrhosis

3, Esophageal varices

4, Hepatitis

Plan

Admit To ICU

Iv and Fluids

Ammonia blood level

Type and cross

Blood transfusion

Consult GI

Neuo checks q 2 hr

References

Horvatits, T., Schulze zur Wiesch, J., Lütgehetmann, M., Lohse, A. W., & Pischke, S. (2019). The clinical perspective on hepatitis E. Viruses, 11(7), 617.

Sharma, M., Singh, S., Desai, V., Shah, V. H., Kamath, P. S., Murad, M. H., & Simonetto, D. A. (2019). Comparison of therapies for primary prevention of esophageal variceal bleeding: a systematic review and network meta‐analysis. Hepatology, 69(4), 1657-1675.