Medical Student Corner
Hematemesis

Each issue, Q Fever! presents a challenging clinical conundrum to test readers' problem-solving skills and illustrate bread-and-butter medical principles. Good luck!

P.N. is a 39-year-old woman who presents to the Emergency Room with the chief complaint of upper abdominal pain and vomiting, with bright red blood present in the vomitus. These symptoms began six hours ago at 7PM. Prior to that she had felt fine.

She denies fevers, chest pain, diarrhea, or black tarry stools.

Past medical history is significant for low back pain, for which she takes ibuprofen. She is on no other medications.

She does not smoke and denies alcohol intake, and is employed as a clerk. She is single and has no children.

Family history is noncontributory.

On exam, she is in no distress.
Vital signs: BP 90/60, HR 130, R 16, T 98.5F.
Lungs are clear bilaterally.
Heart exam is normal.
Abdomen is soft, with moderate epigastric tenderness. Normal bowel sounds. No rebound or guarding.
Extremities show no edema.
Rectal exam shows dark guaiac positive stool.

A nasogastric lavage is performed, which shows coffee grounds and some bright red streaking.

Labs, including CBC, PT/PTT, Type & Cross, and electrolytes, are pending.

You call the gastroenterology consult service, and speak to Dr. Paul Bailey, the GI Fellow on call. He informs you that an urgent GI consultation is not necessary, and demands to know why he was called at this hour. He notes irritatedly that you should, at the very least, have had the lab results before calling him. He concludes that you should hydrate the patient and consent her for a possible endoscopy the next day.

You're perplexed until you glance up at the wall, and notice this:

What's going on?

Answer:
GI Upset

The correct diagnosis in this case is GI Upset.

GI is Upset because you called them in the middle of the night, instead of waiting until the next morning.

From GI’s perspective, you should really think twice before disrupting their restful slumber with minor patient issues and concerns at 2 AM. They would appreciate if you could handle such things yourself, since you are there in the ER and they are in bed.

The management of GI Upset is often challenging, and the required skills can take years to develop.

In the current scenario, the patient should be informed that she is bleeding from her upper gastrointestinal tract, and that a procedure needs to be done immediately. Add that this procedure will actually be done sometime late the next day, and express optimism that exsanguination will not occur prior to that.

As a clinician, it is important to remember that GI Upset cannot be prevented, and may flare up at any time. Nevertheless, even severe GI Upset should not deter your delivery of proper patient care; in such cases, it may be helpful to contact your Behavioral Health professional or chaplain for advice.