CHIEF COMPLAINT: syncope
HPI: Patient is a 62-year-old male brought in by rescue ambulance from home after apparent
syncopal episode, hypotension and GI bleeding. According to the patient he has no past
medical history however he has been experiencing dark stools for the last 2-3 years. Per report
he walked into the kitchen and suddenly collapsed. Rescue states he lost about 100-150 cc of
bright red blood. In addition he has been having black stool today. Upon arrival rescue states
his systolic blood pressure was in the 60s. He has received about 400 cc of NS upon arrival
was no longer hypotensive. He has never seen a GI specialist. He has no primary care
physician. Denies any pain. Occasional ETOH only. No other related medical history.
PAST MEDICAL HISTORY: "GI problems"
PAST SURGICAL HISTORY: None
FAMILY HISTORY: Noncontributing
SOCIAL HISTORY: No smoking, occasional Alcohol, No Drugs, recent immigrant from China,
no PMD
ALLERGIES: NKDA, patient denies any history of allergy to iodine or contrast media.
HOME MEDICATIONS: unavailable
REVIEW OF SYSTEMS:
General: NEG for chills, fevers
HEENT: NEG for blurry vision, sore throat
CV: NEG for palpitations, chest pain
Lung: NEG for cough, shortness of breath
Abd: NEG for abdominal pain, diarrhea
GU: NEG for hematuria, dysuria
Skin: NEG for lesions, rash
Extremity: NEG for joint pain, back pain
Neuro: NEG for headache
Psych: NEG for confusion, agitation
All other systems were reviewed by me and were negative except as otherwise indicated above
PHYSICAL EXAM:
GENERAL APPEARANCE: nontoxic, no acute distress.
HEENT: Head atraumatic/normocephalic. EOMI. bright red blood is noted from mouth and
nares. No oral trauma noted.
NECK: Supple, no lymphadenopathy. Full ROM
LUNGS: Airway intact. Lungs clear to auscultation bilaterally. No wheezes, rhonchi, rales.
+breath sounds. Breathing unlabored.
HEART: Rate and rhythm regular, no murmurs, rubs or gallops. +S1+S2. No JVD.
ABDOMEN: Mild left upper quadrant tenderness to palpation, soft, nondistended. No guarding
or rebound. +bowel sounds. Negative Murphys and McBurney's. No CVA ttp.
EXTREMITIES: No pedal edema, no calf swelling or ttp. Peripheral pulses palpated
NEUROLOGIC: Awake, alert. Moving extremities purposefully. Sensation grossly intact.
SKIN: Warm, dry, pale
PSYCH: Calm, not agitated.
Vital Signs: Pulse oximetry is normal, interpreted by myself.
Blood Pressure: 95/64 LYING L ARM
O2 Saturation: 98 %
Pulse: 81 monitor
Respiration: 13
Temperature: 98.6 F 37 C RECTAL
EKG: Read extemporaneously by me
EKG shows Sinus rhythm 83 beats per minute
No changes indicating acute ischemia
DIAGNOSTIC IMAGING:
Read by radiologist. Reports reviewed by me.
CT Ab/Pelvis Findings:
The visualized lung bases are clear.
The liver is unremarkable.
The gallbladder is unremarkable.
The pancreas, spleen and adrenal glands are unremarkable.
No calculus is identified within either kidney, along the expected course of the ureters or within
the urinary bladder. There is no evidence of hydronephrosis or asymmetric perirenal
inflammatory change.
The urinary bladder is unremarkable. The pelvic organs are remarkable for dystrophic
calcifications in the prostate gland.
The visualized bowel are remarkable for a fluid and debris distended stomach. Nonspecific
bowel wall thickening of the ascending and transverse colon. Normal appendix. There is no
evidence of obstruction. There is no extraluminal gas or fluid.
There are no enlarged lymph nodes.
There is scattered calcified atherosclerotic disease of the abdominal aorta.
The osseous structures are unremarkable.
Impression:
Significant distention of the gastric lumen with fluid and solid debris may be secondary to a
recent large meal or gastric bezoar. Correlate clinically.
Mild bowel wall thickening of the ascending and transverse colon suspicious for infectious or
inflammatory colitis. No free air, free fluid or bowel obstruction.
---------------------------------------------------------------------------------------------------------------------------CT head Findings:
There is a small, old right high parietal infarct. The ventricles, cisterns and remaining sulci are
normal for the patient's age. There is no midline shift. There is no extra-axial fluid collection.
There is no evidence of acute intracranial hemorrhage.
The white matter is within normal limits. The gray-white differentiation is maintained.
The basal ganglia and thalami are unremarkable. The brainstem and cerebellum are within
normal limits.
The sellar and parasellar regions are unremarkable.
The visualized paranasal sinuses demonstrate moderate to severe mucosal thickening. The
mastoid air cells are clear. The orbits demonstrate an old fracture of the left medial orbital wall.
The bony calvarium is unremarkable. The soft tissues of the scalp are unremarkable.
Impression:
1. No acute intracranial findings. No evidence of acute intracranial hemorrhage, midline shift or
mass effect.
2. Moderate to severe chronic pansinusitis.
3. Old left orbital fracture.
-----------------------------------------------------------------------------------------------------------------------Chest x-ray Findings:
The cardiac silhouette was normal. The pulmonary vasculature was normal.
No consolidations were seen.
The osseous structures were normal.
Impression:
Normal chest.
LABS:
WBC: 9.3 x10^3
HEMOGLOBIN: 11.6 g/dL L
HEMATOCRIT: 34.7 % L
PLATELETS: 160 10^3
SODIUM: 140 mmol/L
POTASSIUM: 4.5 mmol/L
CHLORIDE: 111 mmol/L H
CO2: 25 mmol/L
BUN: 31 mg/dL H
CREATININE: 0.9 mg/dL
BUN/CREAT: 34.4 H
GLUCOSE: 111 mg/dL H
CALCIUM: 7.9 mg/dL L
SGOT/AST.: 19 U/L
ALKALINE PHOS: 47 U/L
TOTAL BILI: 0.2 mg/dL
TOTAL PROTEIN: 5.7 g/dL L
ALBUMIN: 3.2 g/dL L
GLOBULIN: 2.5 g/dL
SGPT/ALT: 16 U/L
ANION GAP: 9
LIPASE.: 40 U/L
TROPONIN I.: <0.012 ng/mL
ALCOHOL: <10.0 mg/dL
MDM:
Differential diagnosis include but not limited to: Upper GI bleed, esophageal varices, acute
gastritis, acute electrolyte abnormality, acute anemia, sepsis, ICH, CVA, ACS, cardiac
arrhythmia.
CBC showed no evidence of acute infection or anemia.
CMP largely unremarkable. Chloride 111, BUN 31, Crt 0.9, Ca 7.9
EKG showed no findings consistent with acute ischemia. Troponin negative.
Patient is alert and oriented, denies any pain upon arrival. States he has never seen a doctor
regarding his " GI issues". IV fluids, octreotide and Protonix initiated immediately.
CT head was negative for any acute findings. Chest x-ray was negative. CT abdomen pelvis
showed possible colitis?
Patient is positively responsive to IV fluids however noted to become repeatedly hypotensive
with systolic in the 70s upon completion of fluids. He is carefully monitored while in the
emergency department. I discussed these findings with admitting physician, he will be admitted
to telemetry under careful monitoring may need to be upgraded depending on hypotension
Medications: 2L NS, octreotide IV, Protonix 40mg IV push
RE-EVALUATION:
Upon re-evaluation pt is noted to be resting comfortably, in no acute distress.
CLINICAL IMPRESSION:
syncope
upper GI bleed
hypotension