A Case Report:

Upper Gastrointestinal Bleeding in a 58 y/o Alcoholic Patient with Stigmata of Chronic Liver Disease
JI Joshua Balunsay-Camaing JI Prima Donna Estorninos JI Allen Jurado JI Tara Angela Krysteena Oliveros-Dela Cruz JI Laura Angela Palisoc-Saberola JI Elizabeth Jeremmie Reyes PGI John Paul Benitez PGI Joyce David PGI Justin Melissa Dureza PGI Juliet Kristine Evangelista PGI Julie Gayon

LEARNING OBJECTIVES
1. To present a case of Upper Gastrointestinal Bleeding with Laennecs Cirrhosis 2. To differentiate Upper Gastrointestinal Bleeding from Lower Intestinal Bleeding and Swallowed Blood from Massive Hemoptysis or Epistaxis
3. To identify the tell tale signs of Liver Cirrhosis present in our case

LEARNING OBJECTIVES
4. To establish the possible causes of Upper GI bleeding in the setting of Laennecs Cirrhosis
5. To devise strategy on how to diagnose and manage Upper GI Bleeding in the setting of Laennecs Cirrhosis.

GENERAL DATA
D. E. 58-year-old, Male, Widower Filipino, Roman Catholic Retired jeepney driver Bulacan resident First admission at MCU-FDTMF Hospital on June 24, 2012

CHIEF COMPLAINT

Melena

HISTORY OF PRESENT ILLNESS

Abdominal enlargement Abdominal fullness

1 year PTA

Consult
Ultrasound & Endoscopy done Lost to follow-up

HISTORY OF PRESENT ILLNESS

6 months PTA

Previous symptoms Jaundice Flank pain Consult/Admitted Shockwave Lithotripsy, Left was done Discharged

HISTORY OF PRESENT ILLNESS

5 months PTA

Regular follow-up Dyspnea Admitted COPD Liver Cirrhosis Discharged

HISTORY OF PRESENT ILLNESS

4 months PTA

Regular follow-up Abdominal enlargement, jaundice, & dyspnea Liver Function Tests were done Home medications Lost to follow up

HISTORY OF PRESENT ILLNESS

1 day PTA

Previous symptoms persisted Hematemesis Body weakness Consult

HISTORY OF PRESENT ILLNESS

Few hours PTA

Melena
Consult ADMISSION

PAST MEDICAL HISTORY (+) Hypertensive for 6 months

Amlodipine 10 mg/tablet once a day (+) good compliance Usual BP = 120/80 Highest BP =170/100

(+) Previous Hospitalizations No blood transfusion

FAMILY HISTORY (+) Hypertension paternal

PERSONAL & SOCIAL HISTORY

30 pack year smoking history 1 bottle of gin 2-3 times a week or sometimes 5-6 bottles of beer 3-4 times a week for almost 40 years Sedentary lifestyle Unrestricted diet

REVIEW OF SYSTEMS
General Skin
(+) weight gain, (+) poor appetite, (+) easy fatigability (-) rashes, (-) change in color of moles

HEENT

(-) headache, (-) dizziness, no blurring of vision (-) tinnitus, (-) hearing loss, (-) ear discharge, (-) colds

REVIEW OF SYSTEMS
Chest & Lungs
(-) hemoptysis, (+) dyspnea, (-) cough

Heart

(+) orthopnea, (+) paroxysmal nocturnal dyspnea, (-) palpitations

Abdomen

(-) abdominal pain, (-) dysphagia, (-) diarrhea, (-) constipation, (-) hematochezia, (-) vomiting

REVIEW OF SYSTEMS
Genitourinary
(-) polydipsia, (-) polyuria, (-) polyphagia, (-) nocturia, (-) hematuria, (-) dysuria

Neurologic

(-) diaphoresis, (-) seizures, (-) loss of consciousness, (-)sensorial changes

PHYSICAL EXAMINATION
General Survey:
Patient is chronically-ill, alert, large built, 57 in height, weighing 95 kg and BMI of 32 kg/m2, with labored breathing, brown skin with yellowish-tinge, and slightly slurred speech. He is sad-looking and has a depressed mood. He is clad in a white hospital gown. He exudes an malodorous scent. His hair is short and wellkempt. He is lying on his bed. He has difficulty in getting-up. He has spontaneous movements with no tics or mannerisms. He has no gross deformities.

PHYSICAL EXAMINATION
Vital Signs:

BP: Temperature: Heart Rate: Respiratory Rate: Pain Scale:

110/70 36.9C 77 bpm 22/rpm 0/10

PHYSICAL EXAMINATION
Skin
icteric, dry, coarse, warm, elastic & has good skin turgor, (+) 2-3mm petechiae scattered on his left upper chest red in color that blanched on pressure. Hair is black, short, coarse, and is equally distributed, (+) Terrys nails with clubbing

PHYSICAL EXAMINATION
HEENT:
Head
Round-shaped, symmetrical with abundant, equally distributed hair, no lesions in the scalp, no area of tenderness, symmetrical face. Facial skin color is icteric with no areas of hyper-or hypopigmentations, with no lesions.

PHYSICAL EXAMINATION
HEENT:
Eyes Eyes are symmetrically aligned, Eyebrows and Eyelashes are thick and fairly distributed, No periorbital scaliness or edema, No lumps or swelling of the lacrimal apparatus, Icteric sclerae and palpebral conjunctiva, No opacities of the cornea and lens, Iris is fairly flat, casting no shadows, Pupil size is 4 mm equally reactive to light, constricting to 2 mm, intact direct and consensual reaction, Intact extraocular movement and convergence test, disc margins sharp; no haemorrhages or exudates, No arteriolar narrowing

PHYSICAL EXAMINATION
HEENT:
Ears
Symmetrical, (-) deformity of the auricle, Right and left canals are both clear of wax, TM with good cone of light, Acuity good to whispered voice, Sound is equally heard in both ears during Webers test, AC>BC

PHYSICAL EXAMINATION
HEENT:
Nose
(+) alar flaring, symmetrical, (-) deformity, obstruction, pink mucosa, septum is midline

PHYSICAL EXAMINATION
HEENT: Throat
Pale and dry lips, (-) canker sores, (+) dental caries and poor dentition, roof of the mouth is hard, whitish tongue, No sores on the floor of the mouth, No tonsilopharyngeal congestion

PHYSICAL EXAMINATION
Neck:
Broad & short neck, supple on all movements, No lesions, no neck vein engorgement (-) cervical lymphadenopathy Midline trachea Thyroid gland is about 15 grams (-) carotid bruit

PHYSICAL EXAMINATION
Chest/Lungs
Symmetrical, (+) gynecomastia, (-) cyanosis (-) audible wheezing or stridor (-) contraction of the accessory muscles Transverse diameter is much wider than the AP diameter Symmetric chest expansion, (+) retractions, (-) lagging (-) masses, (-) tenderness, tactile fremitus is equal in both lungs, Resonant both in anterior and posterior Vesicular breath sounds, (-) crackles, wheeze or rhonchi (-) bronchophony, egophony and whispered pectoriloquy

PHYSICAL EXAMINATION
Heart
Adynamic precordium, (-) visible pulsations, apex beat is at 5th ICS, left MCL, (-) scars, lesions, signs of trauma and previous surgery, (-) precordial bulging JVP is 3 cm above suprasternal angle Apex beat is palpable in the 5th ICS midclavicular line. Size is about 2 cm and tapping Crisp S1 and S2, at the base, S2>S1, at the apex S1>S2 (-) murmurs

PHYSICAL EXAMINATION
Abdomen:
Abdomen is globular, shiny & tensed, icteric skin, with visible dilated superficial abdominal veins, everted umbilicus, Abdominal girth=42 inches (+) normoactive bowel sounds, (-) abdominal, lumbar, and iliac bruit, (-) friction rubs (-) palpable masses Liver edge is knobby, (+) rebound tenderness on Left Upper Quadrant, liver span=8.0 cm Right MCL Traubes space is dull, rest of the abdomen is tympanitic (+) shifting dullness, (+) fluid wave test

PHYSICAL EXAMINATION
Peripheral Vascular
Extremities are warm (+) bipedal edema No varicosities or stasis changes Calves are supple and nontender (-) femoral or abdominal bruits Brachial, radial, femoral, popliteal, dorsalis pedis (DP), and posterior tibial (PT) pulses are 2+ and symmetric

PHYSICAL EXAMINATION
Back and Spines
Symmetrical (-) spasm and tenderness of the paravertebral and back muscles

PHYSICAL EXAMINATION
Extremities
Paired joints are symmetrical (+) bipedal edema (-) evidence of redness, skin rash, subcutaneous nodules, cysts, scars (-) tenderness upon firm pressure along the joint margins, and over tendons and ligaments Full range of motion

PHYSICAL EXAMINATION
Neurological:
CEREBRAL Alert but appears anxious Speaks in soft tone Thought is coherent and oriented to person, place and time (-) aphasia, executed verbal commands with slight limitation Responds to questions correctly and was able to repeat short sentences Able to calculate simple arithmetic problems Memory to both remote and recent is intact, no agnosia, no apraxia

PHYSICAL EXAMINATION
Neurological:
Cranial Nerves
I II III, IV, VI V VII VIII IX, X XI XII intact sense of smell pupils equally reactive to light and are 2-3 mm constricted intact extraocular muscles intact corneal reflex (-) facial asymmetry intact hearing intact gag reflex can shrug shoulders tongue is at midline

PHYSICAL EXAMINATION
Neurological:

Motor
(-) atrophy of the muscles of both upper and lower extremities, good muscle tone

Motor Strength
Right upper extremities: 5/5 Left upper extremities: 5/5 Right lower extremities: 3/5 Left lower extremities: 3/5 Sensory: Light touch, vibration and sharp or dull pain sensation, and stereognosis are 100% intact throughout the body

PHYSICAL EXAMINATION
Neurological:
Cerebellar Rapid alternating movements, finger-to-nose, heelto-shin test intact (-) pronator drift Tandem walking revealed no ataxia

(-) Babinski reflex

SALIENT FEATURES
58 y/o male Smoker & heavy alcoholic beverage drinker melena Abdominal enlargement & fullness Icteresia Hematemesis Hypertensive Easy fatigability, dyspnea, orthopnea, PND Petecchial rashes Terrys nails with clubbing Globular, shiny, everted umbilicus Visible superficial abdominal veins Liver edge is knobby Dullness on Traube space Bipedal edema

TELL TALE SIGNS OF ALCOHOLIC CIRRHOSIS

-Variceal bleeding -hepatic encephalopathy -Edema -icteresia -ascites -spider angioma -Caput medussae -palmar erythema -Gynecomastia

CLINICAL FEATURES

SOURCE OF BLEEDING

RESPIRATORY TRACT

GASTROINTESTINAL TRACT
pH is acidic Hematemesis Melena hematochezia

Frothy pH is basic Preceded by cough Evidence of epistaxis or gum bleeding Swallowed and appear as melena or occult blood in stool

UGIB VS LGIB

UPPER GI TRACT

LOWER GI TRACT

Hematemesis Melena Hematochezia (massive bleeding >1000ml) Increased Transit Time

Hematochezia Melena if with altered bowel function (constipation) or obstruction, from proximal colon

ABOUT ALCOHOLISM
Quantity and Duration most important
risk factors in the development of alcoholic liver disease

1 beer = 4 ounces of wine = 1 ounce of 80% spirits = 12 g of alcohol Threshold (men) intake >60-80g/d for 10 years Threshold (women) intake >20-40/d for 10 years
Harrisons Principles of Internal Medicine, 17th Edition. McGraw-Hill Companies, Inc., USA: 2008. p 1969.

ABOUT ALCOHOLISM
Ingestion of 160g/d 25-fold increased risk for alcoholic cirrhosis

20-50g/d increased risk for Cirrhosis and Hepatocellular Ca in patients with HCV infection

Harrisons Principles of Internal Medicine, 17th Edition. McGraw-Hill Companies, Inc., USA: 2008. p 1969.

ABOUT ALCOHOLISM
Blood Alcohol Concentration of 80-100 mg/dL legal definition for driving under influence of alcohol
3 oz. (44ml) of ethanol in 77-kg person = 12 oz. of fortified wine = 8 bottles of beer (12 oz. each) = 6 oz. of 100-proof whiskey

Habitual drinkers can tolerate up to 700mg/dL

Robbins and Cotran Pathologic Basis of Disease, 8th Edition. Elsevier, Inc., USA: 2008. p 421-422. Katzung Basic and Clinical Pharmacology, 11th Edition. McGraw-Hill Companies, Inc., USA: 2010. p 365.

ABOUT ALCOHOLISM
100-200 mg/dL impaired motor function, slurred speech, ataxia 200-300 mg/dL emesis, stupor 300-400 mg/dL coma >500 mg/dL death, respiratory arrest

Robbins and Cotran Pathologic Basis of Disease, 8th Edition. Elsevier, Inc., USA: 2008. p 421-422. Katzung Basic and Clinical Pharmacology, 11th Edition. McGraw-Hill Companies, Inc., USA: 2010. p 365.

STIGMATA OF LIVER CIRRHOSIS

PATHOPHYSIOLOGY
Risk Factors for Alcoholic Liver Disease
1. Quantity In men, 40-80g/day produces fatty liver; 160g/day in 10-20 years causes hepatitis or cirrhosis 2. Gender Women>men 3. Hepatitis C Infection

PATHOPHYSIOLOGY
Risk Factors for Alcoholic Liver Disease
4. Genetics genetic polymorphisms (alcohol dehydrogenase, cytochrome p4502E1, and those associated with alcoholism) 5. Malnutrition Obesity and fatty liver from effect of CHO on transcriptional control of lipid synthesis and transport

PATHOPHYSIOLOGY

Results: 1. Acetaldehyde adducts formation 2. Increase ROS formation 3. Increase NADH:NAD+ formation

PATHOPHYSIOLOGY
Chronic Alcoholism

reduced NADH

Impaired assembly and secretion of lipoproteins

peripheral catabolism of fat

lipid biosynthesis

FA uptake & FA oxidation

Gross accumulation of fat in liver cells

PATHOPHYSIOLOGY
Chronic Alcoholism

Decreased intrahepatic GSH levels

Induction of Cytochrome P-450

Oxidative injury to liver

Production of ROS

Interfere with specific enzyme activities Alter hepatocellular function (microtubular formation & protein trafficking) Kupffer cell activation

React with cellular proteins forming protein-acetaldehyde adducts

PATHOPHYSIOLOGY
Continuing alcohol ingestion

Progressive hepatocyte injury (ballooning degeneration, spotty necrosis, PMN infiltrate and fibrosis in the perivenular and perisinusoidal space)

Liver fibrosis and scarring

Liver contracts and shrinks

Decreased liver function

Obstruction of portal circulation

Portal Hypertension (>5 mmHg HVPG)

PATHOPHYSIOLOGY OF ESOPHAGEAL VARICES

Deranged (vascular) architecture

Vasoconstrictor

(dilator) imbalance

Adrenergic System (increased cardiac index) RAA System (renal sodium-water retention

Increased portal blood flow Increased resistance to portal flow

PATHOPHYSIOLOGY OF ASCITES
Portal Hypertension Hypoalbuminemia & Plasma oncotic pressure Splanchnic vasodilation Splanchnic pressure Lymph formation Formation of peripheral edema & ascites Arterial underfilling Activation of vasoconstrictors and antinatriuretic factors Sodium retention

Plasma volume expansion

PATHOPHYSIOLOGY
Portal Hypertension Direct toxic effect of alcohol

Congestive splenomegaly

Diversion of portal blood to systemic circulation

Testicular atrophy

Hypersplenism

Venous collateral shunt

Hormonal abnormalities

LUQ pain Thrombocytopenia

Caput medussae Digital Clubbing

Gynecomastia Decreased body hair Spider angiomatas Palmar Erythema

PATHOPHYSIOLOGY
Decreased Liver Function protein production Clotting factors Bleeding tendencies Bilirubin uptake and storage Hyperbilirubinemia

Hypoalbuminemia

Terrys Nails Muehrcke's lines

Anemia

Icteric sclera Jaundice

PATHOPHYSIOLOGY
Vascular Shunting Impaired removal of Gut-derived neurotoxins

Decreased Hepatic Mass

Ammonia levels

Altered mental status Asterixis

Coma Death

PATHOPHYSIOLOGY

CAUSES OF UGIB IN THE SETTING OF ALCOHOLIC LIVER DISEASE

1. Bleeding Esophageal Varices 2. Gastric/Duodenal Varices (Portal Hypertensive Gastropathy) 1. Gastroduodenal Ulcer 2. Mallory-weiss Tears 3. Erosive Gastritis

CAUSES OF UGIB IN THE SETTING OF ALCOHOLIC LIVER DISEASE

Erosive Gastritis Rule In: (+) melena Rule Out:

Chronic alcohol consumption is not a common cause of erosion in the gastrointestinal tract More commonly related with NSAID abuse

CAUSES OF UGIB IN THE SETTING OF ALCOHOLIC LIVER DISEASE

Gastroduodenal Ulcer Rule In:

(+) melena

Rule Out:
More commonly associated with H.pylori infection and chronic NSAID intake

CAUSES OF UGIB IN THE SETTING OF ALCOHOLIC LIVER DISEASE

Mallory-Weiss Tears Rule In:

(+)melena, (+) chronic intake of alcohol

Rule Out:
Bleeding usually occurs immediately after recent history of severe retching or vomiting Commonly presents as hematemesis

CAUSES OF UGIB IN THE SETTING OF ALCOHOLIC LIVER DISEASE

Gastric/Duodenal Varices (Portal Hypertensive Gastropathy) Rule In:

(+) melena, (+) chronic alcoholism, (+) prominent superficial veins

Rule Out:
Less common in patients with history of chronic alcohol intake

CAUSES OF UGIB IN THE SETTING OF ALCOHOLIC LIVER DISEASE

Bleeding Esophageal Varices Rule In:

(+) melena, (+)chronic alcohol intake Most Common cause of upper GI bleeding in the setting of alcoholic liver cirrhosis

Strongest tendency to bleed

CAUSES OF UGIB IN THE SETTING OF ALCOHOLIC LIVER DISEASE

Definitive Diagnosis is by Esophagogastroduodenoscopy (EGD)

ADMITTING IMPRESSION

UPPER GASTROINTESTINAL BLEEDING

secondary to Bleeding Esophageal Varices

APPROACH TO PATIENT
AT THE EMERGENCY ROOM

Hematemesis Melena

VS: BP120/70 PR=77 bpm RR=22 rpm T=36.9C Chronically illlooking

UGIB secondary to Bleeding Esophageal Varices

Admit to MMW VS q2, I&O qshift IVF D5NM 1L X 60cc/hr NPO except medications CBC, Na, K, Crea, CBG q6, ECG, CXR Pantoprazole drip at 6mg/hr Lactulose syrup 30cc BID Standby 2U PRBC For EGD once stable

LABORATORY RESULTS
COMPONENT RBC Hemoglobin RESULT 3.19 x 10 ^12/L 12.10 g/dL REFERENCE 4.6 6.20 13.5 18.0

Hematocrit
WBC Segmenters Lymphocytes

0.37
12.3 x 10^9/L 0.77 0.20

0.42 0.50
4.5 11 0.56 0.34

Monocytes
Platelet count MCV MCH MCHC

0.01
Decreased 115.7 fl 38 pg 0.33

0.04
150 400 80 96 27 31 0.32 0.36

LABORATORY RESULTS
CBG = 7.5 mmol/L

Clinical Chemistry Creatinine Sodium Potassium

RESULT 0.89 mg/dl 132.1 mmol/L 2.74 mmol/L

REFEREN CE 0.60-1.20 135-148 3.5-5.3

LABORATORY RESULTS CHEST XRAY

Lung fields are clear Heart is not enlarged The right hemidiaphragm is elevated Both sulci are intact

IMPRESSION: Elevated right hemidiaphragm

LABORATORY RESULTS 12 LEAD ECG

Sinus tachycardia Non specific ST-T wave changes

APPROACH TO PATIENT WITH GI BLEEDING

HISTORY

Weakness, dizziness, syncope associated with hematemesis and melena A brisk UGIB manifests as hematochezia History of dyspepsia, ulcer disease, early satiety, and NSAID or aspirin use Prior history of ulcers

APPROACH TO PATIENT WITH GI BLEEDING

HISTORY

In a more subacute phase, with a history of dyspepsia and occult intestinal bleeding History of chronic alcohol use of more than 50 g/d or chronic hepatitis (B or C) Subcutaneous emphysema with a history of vomiting (Boerhaave syndrome) Presence of postural hypotension

APPROACH TO PATIENT WITH GI BLEEDING

PHYSICAL EXAMINATION

GOAL: To evaluate for shock and blood loss

Assess the patient for hemodynamic instability and clinical signs of poor perfusion Hemodynamic compromise: tachycardia of more than 100 bpm Systolic BP <90 mm Hg cool extremities Syncope other obvious signs of shock

TILT Test
Signs of chronic liver disease including spider angiomata, gynecomastia, increased luneals, splenomegaly, ascites, pedal edema, and asterixis Signs of tumor: nodular liver, an abdominal mass, and enlarged and firm lymph nodes

COURSE IN THE WARD

DAY OF ADMISSION

Difficulty of Breathing Melena

VS: BP=100/70 PR=100 bpm RR=23rpm T=36.0C Chronically illlooking

UGIB secondary to BEV

KCl drip at 5 mEq/hr Furosemide 20mg/IV

COURSE IN THE WARD

1ST DAY OF HOSPITALIZATION

Difficulty of Breathing Hematemesis Melena

VS: BP=90/60 PR=120 bpm RR=26rpm T=37.3C Chronically illlooking

UGIB secondary to BEV

Refused transfer to MICU-CD

For transfusion of 1 unit PRBC Transfer to MICUCD Transfuse 4 U FFP Somatostatin drip PNSS 250cc + 3mg X 12hrs Somatostatin 250 mcg/IV Lactulose 30cc TID Vit K 10mg/amp, q8 X 3 days Repeat CBC with APC

LABORATORY RESULTS
COMPONENT RBC Hemoglobin RESULT 3.21 x 10 ^12/L 12.20 g/dL REFERENCE 4.6 6.20 13.5 18.0

Hematocrit
WBC Segmenters Lymphocytes

0.37
12.34x 10^9/L 0.88 0.09

0.42 0.50
4.5 11 0.56 0.34

Monocytes
Platelet count MCV MCH MCHC

0.03
Reduced 114.9 fl 38 pg 0.33

0.04
150 400 80 96 27 31 0.32 0.36

LABORATORY RESULTS
PT = 37.7 secs (12-14 sec) PA = 36.9% (100%) Control: 13.9 secs

INR = 3.95 (RV 1.0-1.3)

PTT = 40.7 secs (Control 29.5 secs)

COURSE IN THE WARD

2ND DAY OF HOSPITALIZATION

Hematemesis Hematochezia 2x (+) easy fatigability

VS: BP=119/71 PR=137 bpm RR=36rpm T=36.8C Awake, weaklooking

UGIB secondary to BEV

Refused Intubation

Repeat PTPA after last dose of Vit K Continue KCl drip Levofloxacin 500mg/IV OD For gastroscopy Standby 2 units PRBC

LABORATORY RESULTS
COMPONENT RBC Hemoglobin RESULT 2.2 x 10 ^12/L 8.4 g/dL REFERENCE 4.6 6.20 13.5 18.0

Hematocrit
WBC Segmenters Lymphocytes

0.26
17.3x 10^9/L 0.90 0.08

0.42 0.50
4.5 11 0.56 0.34

Monocytes
Platelet count MCV MCH MCHC

0.02
77 116 fl 38.3 pg 0.33

0.04
150 400 80 96 27 31 0.32 0.36

LABORATORY RESULTS Serum Potassium = 2.60 mmol/L

PT = 29.9 secs (12-14 sec) PA = 49.1% (100%) Control: 13.3 secs INR = 2.99 (RV 1.0-1.3)

LABORATORY RESULTS
DATE & TIME 6/22/12 7:13 pm 6/22/12 12:00 am 6/23/12 06:00 am 6/23/12 12:00 pm 6/22/12 06:00 pm 6/24/12 12:00 am 6/24/12 06:00 am CBG RESULTS 7.5 mmol/L 7.7 mmol/L 5.4 mmol/L 5.9 mmol/L 6.3 mmol/L 7.2 mmol/L 8.1 mmol/L

6/24/12 12:00 pm
6/24/12 06:00 pm 6/25/12 12:00 am 6/25/12 06:00 am

7.8 mmol/L
7.3 mmol/L 7.5 mmol/L 7.3 mmol/L

COURSE IN THE WARD

3RD DAY OF HOSPITALIZATION

Difficulty of Breathing

Refused Intubation

VS: BP=120/80 PR=170 bpm RR=27rpm T=37.0C O2 sat=70% (+) Crackles both lung fields

UGIB secondary to BEV

Hold gastroscopy Lactulose 30cc q6 Hold CBG monitoring Spironolactone 25mg/tab, OD Digoxn 0.25mg/IV, ampule O2 at 10LPM via face mask Furosemide 20mg/IV For ABGs now

COURSE IN THE WARD

4TH DAY OF HOSPITALIZATION

Difficulty of Breathing

Refused Intubation

VS: BP=120/80 PR=170 bpm RR=27rpm T=37.0C O2 sat=5070% (+) Crackles CLINICALLY DEAD at 3:43am

UGIB secondary to BEV

Bicarbonate 150 mEqs slow IV push

Do rhythm strip Post-mortem Care

FINAL DIAGNOSIS