a 45-year-old man with vomiting and light-headedness

last week charlie presented the case of a man with a short history of vomiting what he thought was blood

(he also had left-sided upper abdominal pain - we very briefly thought about what might cause this but the main focus of our enquiry was GI bleeding)
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we discussed the important issue of not assuming this is a GI bleed

1) it could be from the mouth or possibly respiratory tract
2) be sceptical about the fluid being blood: either see it yourself (having seen it before) or only believe someone you trust (eg experienced nurse) [the story of the lady with the femoral hernia]
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we then talked about 1) assessing severity & 2) possible diagnoses
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1) severity

questions about the vomit, eg volume, frequency
questions representing volume depletion and /or anaemia, eg dizziness on standing, syncope

2) the potential diagnoses:

- ulcer disease
- drug-induced erosions
- liver disease (abnormal clotting/varices)
- cancer
- Mallory-Weiss tears

we briefly explored the questions that might let us differentiate between these conditions
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we then went to the bedside & wondered what broad questions clinical examination should try to answer

- is this patient hypovolaemic?
- does this patient have chronic liver disease?
- does this patient have cancer?

we did not manage to examine the patient
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we discussed then discussed the key investigations, emphasing the need for a group & save/cross-match sample, and the requirement to fill a blue-top (citrate) bottle to the brim

we also mentioned that the Hb concentration might not be reliable initially
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it turned out that the patient had an urgent OGD which showed oesophageal varices

he was also given a large volumes of intravenous colloid & crystalloid & he subsequently went into pulmonary oedema, for which a small dose of diuretic was required
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it would be ideal if we can follow him up & see how his varices are managed in the long-term


Salaam


sabih