A 29 y/o male presents with syncope. He states he was with friends when he got up to get a beer; he became dizzy, then suddenly passed out. He has no significant medical problems, no hospitalizations, and no surgeries. He only takes Motrin for his chronic knee pain (he used to play college football), but he ran out and has been taking his mom’s aspirin for the past week. He did not sustain any head trauma (his friends noted he slumped back onto the couch), he has no neck pain, no chest pain, no SOB, no abdominal pain, no fevers, vomiting, cough, and no problems with bowl or bladder. No change in stool.

PE: BP=100/70, Pulse=110, RR=20, temp=99, Sat 96% on RA. WDWN athletic male in no distress resting comfortably on the bed. HEENT unremarkable. Heart RRR but tachy, lungs clear bilaterally. Abdomen soft, nontender, normal BS. Ext-normal. Rectal: black stool, guiac positive. (Note it took 3 full minutes to convince this patient that he really did need to have this exam done—he was mortified and only after substantial discussion did he allow the rectal exam. He reiterated several times: "I'm not letting you put you finger in there").

The patient is placed on a monitor, 2 IV lines are established, and labs are sent.

1. Does this patient need a NG tube? How helpful is it if it is negative?

2. If the patient had hematochezia instead of melena, would he need an NG tube?

Patient refused NG tube (("I'm not letting you put that in there!"), and labs returned with hemoglobin of 9.5, WBC 12,000, platelets of 250, and Bun 24, Cr=1.0.All other labs and work-up are unremarkable. The patient is admitted to the floor with serial H/H, GI and surgery consults, and 2 units of blood cross-matched and available. Three hours after admission, you are called by the floor senior and told that this patient just “coded after vomiting over 1 liter of blood”. He is fluid resuscitated and transferred to the MICU.

3. In addition to blood transfusions, what other interventions can you suggest to the senior?

Click here for answers and to respond