s********4
发帖数: 64 | 1 Chief Complaint: “I have blood in my stool, and nausea with coffee-ground
emesis.”
History of Present Illness: TH is a 55-year-old man with a past medical
history significant for liver cirrhosis secondary to alcoholic liver disease
and portal hypertension with multiple episodes of esophageal varices who
presented to the emergency room with a two week history of black tarry
stools 2-4 times per day sometimes mixed with bright blood. He also had some
nausea with intermittent vomiting for the same time period, which contained
clear liquid only until two days ago when he noticed some coffee ground
particles. He has not taken any aspirin or NSAIDs, and his last alcohol
drink was 4 years ago. He denies chest pain, shortness of breath, fevers,
chills, abdominal pain, or difficulty with urination. He was noted to be
mildly tachycardic, but his blood pressure was stable at 110/70. His
hemoglobin and hematocrit in the emergency room were 9.9 and 29, so he was
subsequently admitted to the medical intensive care unit for further
evaluation. His repeat Hgb/Hct two hours later showed a further drop in the
hemoglobin at 8.1, and he was started on IV lansoprazole (PO omeprazole
held) and octreotide drips. An esophagogastroduodenoscopy was performed for
evaluation of melena the following day, and the results showed three
duodenal ulcers. The patient tolerated the procedures and medications well,
and the ulcers appear to be healing. The octreotide drip was discontinued
after three days of therapy.
Past Medical History:
1. Child-Pugh class A cirrhosis secondary to alcoholic liver disease
2. CAD with 3-vessel CABG 8 years ago
3. Recurrent GI bleed from small bowel varices and portal hypertensive
enteropathy
4. S/p TIPS procedure 3 years ago
5. S/p Portacaval shunt 3 years ago, complicated by a wound infection (
MRSA+)
6. Insulin dependent diabetes
7. Hypertension
8. Gastroesophageal reflux disease
9. History of pancreatitis (4 and 8 years ago)
10. Depression
11. Insomnia
Admission Medications:
Acetaminophen 650mg PO q8h prn
Atorvastatin 40mg PO qhs
Iron sulfate 325mg PO TID
Fluoxetine 40mg PO daily
Folic acid 1mg PO daily
Furosemide 40mg PO daily
Insulin glargine 60units subQ qhs
Insulin lispro 12U am, 15U noon, 15U pm subQ
Lisinopril 5mg PO daily
Metoprolol 12.5mg PO BID
Multivitamin PO daily
Omeprazole 20mg PO daily
Potassium chloride 20mEq PO daily
Trazodone 200mg PO qhs
Nitroglycerin 0.4mg SL prn
Medications Started in MICU:
Levofloxacin 500mg IV q24h.
Octreotide 50 mcg/hr IV– stopped after three days
Pantoprazole 8 mg/hr IV
Ondansetron inj. 4mg q6h prn
Mupirocin cream 2% BID
Drug Allergies: No known drug allergies.
Family history: His father died of lung cancer at the age of 64. His mother
died of heart disease in her 70s. He has one sister who died of breast
cancer at the age of 60. He has three daughters, and all of them are in
good health.
Social History: He is married and lives with his wife. He has a 30 pack
year history of smoking and currently smokes 1-2 cigarettes per day. He
used to drink alcohol heavily but did not drink for the past 4 years. He
denies any history of illicit drug use or IV drug abuse in the past.
Labs and Vitals (day 3 of hospitalization):
Height 175 cm, Weight 81 kg
Temp 37.0 C, Pulse 72 bpm, RR 13, BP 90/50 mmHg
INR 1.6
Hgb 10.5 g/dL
Hct 30%
Plt 169 x 109/L
Alk phos 58 IU/L
GGT 52 U/L
AST 32 IU/L
ALT 24 IU/L
SCr 1.1 mg/dL
Glc 113 mg/dL |
s********4
发帖数: 64 | |
s********4
发帖数: 64 | |
l******k
发帖数: 27533 | 4 不是高手，抛砖引玉
1. May consider propranolol if still has recurrent variceal bleeding after
TIPS and portacaval shunt
2. If intra-abdominal infection is suspected and ABX is needed, vancomycin
should be started due to the Hx of MRSA wound infection, and metronidazole
should be added for anaerobic coverage. Cultures are needed.
3. change Protonix drip to BID IV push after 72 hours infusion if active
bleeding stopped
5. do iron panel. If need iron supplement, us IV iron, and D/C oral iron for
GI adverse effects
Question:
BP dropped to 90/50: did pt receive any RBC or IV fluids? what's WBC and MAP?
disease
some
contained
【在 s********4 的大作中提到】
: Chief Complaint: “I have blood in my stool, and nausea with coffee-ground
: emesis.”
: History of Present Illness: TH is a 55-year-old man with a past medical
: history significant for liver cirrhosis secondary to alcoholic liver disease
: and portal hypertension with multiple episodes of esophageal varices who
: presented to the emergency room with a two week history of black tarry
: stools 2-4 times per day sometimes mixed with bright blood. He also had some
: nausea with intermittent vomiting for the same time period, which contained
: clear liquid only until two days ago when he noticed some coffee ground
: particles. He has not taken any aspirin or NSAIDs, and his last alcohol
|
u*******s
发帖数: 688 | 5 Some quick thoughts:
Check iron and potassium level.
May not need TID ferrous sulfate since it's so corrosive to the gi tract. Fe
is hard to absorb with low acid production from the ppi anyway. May give
with vit C but another pill burden. Suggest once daily or dc until ulcers
completely heal.
Potassium chloride may be inappropriate during active gi bleeding as well.
Consider if Lasix is less appropriate compared to hctz.
Use protonix 40 mg daily for 4 weeks for duodenal ulcers. |
l******k
发帖数: 27533 | 6 Why HCTZ is more appropriate than Lasix to diurese cirrhosis pts?
Potassium GI erosion problem can be easily fixed by giving IV potassium
chloride
However, if pt is hypotension/shock, Lasix may need to be held
It's not the standard practice to change Protonix drip directly to 40 mg
daily for upper GI bleeding
Fe
【在 u*******s 的大作中提到】
: Some quick thoughts:
: Check iron and potassium level.
: May not need TID ferrous sulfate since it's so corrosive to the gi tract. Fe
: is hard to absorb with low acid production from the ppi anyway. May give
: with vit C but another pill burden. Suggest once daily or dc until ulcers
: completely heal.
: Potassium chloride may be inappropriate during active gi bleeding as well.
: Consider if Lasix is less appropriate compared to hctz.
: Use protonix 40 mg daily for 4 weeks for duodenal ulcers.
|
u*******s
发帖数: 688 | 7 Hctz requires no hepatic impairment dosage adjustment and is less potent
than Lasix. Lasix causes increased sensitivity to hypokalemia and increased
volume depletion in cirrhosis pts. Pt is hypotensive. Also with the hctz the
pt may not even need potassium supp any more.
Protonix 40 mg given in a 2 min infusion is on formulary at the hospital I
work at. Different places may have different practice...
【在 l******k 的大作中提到】
: Why HCTZ is more appropriate than Lasix to diurese cirrhosis pts?
: Potassium GI erosion problem can be easily fixed by giving IV potassium
: chloride
: However, if pt is hypotension/shock, Lasix may need to be held
: It's not the standard practice to change Protonix drip directly to 40 mg
: daily for upper GI bleeding
:
: Fe
|
l******k
发帖数: 27533 | 8 Er... I don't think we are on the same page, but it's OK~
It's good to identify PO KCl and iron issues
increased
the
★ 发自iPhone App: ChineseWeb 8.7
【在 u*******s 的大作中提到】
: Hctz requires no hepatic impairment dosage adjustment and is less potent
: than Lasix. Lasix causes increased sensitivity to hypokalemia and increased
: volume depletion in cirrhosis pts. Pt is hypotensive. Also with the hctz the
: pt may not even need potassium supp any more.
: Protonix 40 mg given in a 2 min infusion is on formulary at the hospital I
: work at. Different places may have different practice...
|
u*******s
发帖数: 688 | 9 没关系，讨论而已，没有必要在same page.
今天又看了看,有几个问题：
levaquin在这里的作用是神马？没觉得有必要上abx啊
有几个liver meds，比如apap, lipitor之类的，discharge之后应该由pcp来解决。
metoprolol 12.5 mg bid又有必要吗？血压已经很低了。最好把lasix 和kcl一起get
rid of
还有protonix 8 mg/hr iv太多了，改成40mg qd or bid比较好吧。
不管是iv KCl 还是dc KCl, po KCl 肯定是要改的。
再给病人test for H.pylori |
l******k
发帖数: 27533 | 10 建议把nonvariceal and variceal GI bleeding 学习下再来讨论
这是个典型的acute care patient case
【在 u*******s 的大作中提到】
: 没关系，讨论而已，没有必要在same page.
: 今天又看了看,有几个问题：
: levaquin在这里的作用是神马？没觉得有必要上abx啊
: 有几个liver meds，比如apap, lipitor之类的，discharge之后应该由pcp来解决。
: metoprolol 12.5 mg bid又有必要吗？血压已经很低了。最好把lasix 和kcl一起get
: rid of
: 还有protonix 8 mg/hr iv太多了，改成40mg qd or bid比较好吧。
: 不管是iv KCl 还是dc KCl, po KCl 肯定是要改的。
: 再给病人test for H.pylori
|
s********4
发帖数: 64 | 11 我有几个问题：
1.我们讲的是tips是一个bridge to liver transplant。做了这个以后就没有liver
funx。而这个病人做tips已经是3年前了。是不是可以用propanolol后考虑liver
transplant。
2.病人入院之前的folic acid和iron pill具体的indication是什么啊。这个case就是
要找出drug therapy problem。这是不是unnecessary medication呢·
3.因为pt已经dehydration，是不是要hold furosemide？那相应的HTX应该如何控制。
要不要增加lisinopril的dose。
4.我的理解病人之前take kcl是因为同时on furosemide。如果order lab之后，k
level在正常，是不是就可以也hold kcl呢
5.因为病人有pud 引起的bleeding，是不是也要加上在discharge的时候put pt on
life long ppi （high dose）？
6.大家觉得discharge的时候的meds有什么需要改正的吗
7.需要test h pylori吗？我不知道病人的ulcer是不是可以算stress ulcer。
我没有任何临床经验。GI是刚学的。希望大家多多指教 |
u*******s
发帖数: 688 | 12 谢谢提醒，看出来这是acute care了，呵呵
我去学习了，欢迎同僚继续讨论
【在 l******k 的大作中提到】
: 建议把nonvariceal and variceal GI bleeding 学习下再来讨论
: 这是个典型的acute care patient case
|
s********4
发帖数: 64 | 13
我有几个问题：
1.我们讲的是tips是一个bridge to liver transplant。做了这个以后就没有liver
funx。而这个病人做tips已经是3年前了。是不是可以用propanolol+isosorbide （2nd
prevention of bleeding)后考虑liver transplant。
2.病人入院之前的folic acid和iron pill具体的indication是什么啊。这个case就是
要找出drug therapy problem。这是不是unnecessary medication呢·
3.因为pt已经dehydration，是不是要hold furosemide？那相应的HTX应该如何控制。
要不要增加lisinopril的dose。
4.我的理解病人之前take kcl是因为同时on furosemide。如果order lab之后，k
level在正常，是不是就可以也hold kcl呢
5.因为病人有pud 引起的bleeding，是不是也要加上在discharge的时候put pt on
life long ppi （high dose）？
6.大家觉得discharge的时候的meds有什么需要改正的吗
7.需要test h pylori吗？我不知道病人的ulcer是不是可以算stress ulcer。
8.ondansertron是必要的吗。我们讲的zofran比较多用于化疗引起的n/v。不过我在
micu rotation的时候感觉很多病人都被put on zofran
我没有任何临床经验。GI是刚学的。希望大家多多指教
【在 l******k 的大作中提到】
: 建议把nonvariceal and variceal GI bleeding 学习下再来讨论
: 这是个典型的acute care patient case
|
