tommyk
05-20-2006, 03:29 PM
Hy 2227 Tough Hematology Question
71-year-old man presents to the hospital with an episode of bright red blood per rectum. The patient reports that, a few hours ago, he passed a grossly bloody bowel movement. The passage was associated with some cramping, lower abdominal pain. The patient's past medical history is significant for coronary artery disease and a myocardial infarction 3 years ago. He is poorly compliant with his beta blocker and diuretic therapy, and his blood pressures have run around 140/85 mm Hg. While the patient is on the floor, he has another episode of large-volume, bright red blood in the rectum. His blood pressure is 90/60 mm Hg while supine, and his pulse is 130/min. His hematocrit is 25%. He then begins to complain of substernal chest tightness radiating to his left shoulder. An ECG shows new T wave inversions in the anterior leads. What do you do?
1-Aspirin
2-Cereal, I personally like Cheerios
3-Type and cross, then Blood Transfusion
4-Nitroglycerin IV
5-Nitroglycerin topically
6-Metoprolol
7-CT to find source of the bleed then laser ablation
8-Immediate IV and Lactate Ringers bolus
ans) #3 According to the available data, the patient is presenting with myocardial ischemia in the presence of anemia. The appropriate treatment, therefore, is a blood transfusion. Administration of aspirin would not be appropriate in this man who is passing bright red blood per rectum. This patient's tachycardia is an appropriate response to the anemia and hypovolemia (an effort to maintain oxygen delivery). The administration of a beta blocking agent, therefore, would be inappropriate. The patient's blood pressure (compare it with his previous pressures) while supine strongly suggests hypovolemia. Therefore, the administration of nitroglycerin, either sublingually or topically, therefore, becomes inappropriate. The nitroglycerin will further reduce preload, which in turn, could further compromise the patient's cardiac output and worsen his myocardial ischemia.
71-year-old man presents to the hospital with an episode of bright red blood per rectum. The patient reports that, a few hours ago, he passed a grossly bloody bowel movement. The passage was associated with some cramping, lower abdominal pain. The patient's past medical history is significant for coronary artery disease and a myocardial infarction 3 years ago. He is poorly compliant with his beta blocker and diuretic therapy, and his blood pressures have run around 140/85 mm Hg. While the patient is on the floor, he has another episode of large-volume, bright red blood in the rectum. His blood pressure is 90/60 mm Hg while supine, and his pulse is 130/min. His hematocrit is 25%. He then begins to complain of substernal chest tightness radiating to his left shoulder. An ECG shows new T wave inversions in the anterior leads. What do you do?
1-Aspirin
2-Cereal, I personally like Cheerios
3-Type and cross, then Blood Transfusion
4-Nitroglycerin IV
5-Nitroglycerin topically
6-Metoprolol
7-CT to find source of the bleed then laser ablation
8-Immediate IV and Lactate Ringers bolus
ans) #3 According to the available data, the patient is presenting with myocardial ischemia in the presence of anemia. The appropriate treatment, therefore, is a blood transfusion. Administration of aspirin would not be appropriate in this man who is passing bright red blood per rectum. This patient's tachycardia is an appropriate response to the anemia and hypovolemia (an effort to maintain oxygen delivery). The administration of a beta blocking agent, therefore, would be inappropriate. The patient's blood pressure (compare it with his previous pressures) while supine strongly suggests hypovolemia. Therefore, the administration of nitroglycerin, either sublingually or topically, therefore, becomes inappropriate. The nitroglycerin will further reduce preload, which in turn, could further compromise the patient's cardiac output and worsen his myocardial ischemia.