Dizziness-Upper GI bleed

Question

40-year-old woman who was recently diagnosed with rheumatoid arthritis comes in after complaining of dizziness on standing up since the last three days. She has been in severe pain two weeks prior to this due to a flare-up of her rheumatoid arthritis. How would you assess this patient?

Answer

I would start by taking a focused history of her dizziness that appears to be orthostatic. I would specifically look for history of pre-syncopal symptoms and ask for a history of syncope. I would focus on taking a thorough systems review specifically focusing on the cardiovascular and gastrointestinal system to see if the patient has any other symptoms along with the dizziness that may provide a clue to the underlying etiology, such as iron deficiency anemia or a systemic infection. I would also look into the patient’s recent rheumatoid flare and enquire regarding the medication history. I would also take a brief social history of her background.

A to E Assessment

• Airway: I would ensure the airway is patent and, if necessary, insert an airway adjunct such as OP or NP airway. If the patient is tolerating an airway adjunct, I would be really worried and seek the help of the critical care team after my assessment if there was a problem with the airway assessment.
• Breathing: I would look at the observations, specifically the oxygen saturation and the respiratory rate. If the patient is hypoxic or if the patient has an increased work of breathing, I’ll start the patient on supplemental oxygen therapy. I would also get a PEFR and an ABG done for this patient to see the pH, PO₂, PCO₂, HCO₃, and lactate. I would be very concerned if the HCO₃ and pH are very low. I would also keep an eye out on the electrolytes on the blood gas that was done. I would also arrange a portable CXR for the patient.
• Circulation: I would look at the observations, specifically the BP, heart rate, and CRT. If there is evidence of hypotension or tachycardia, I would give a fluid challenge to the patient to see if there is an adequate response. If the patient remains hypotensive despite the first fluid challenge, I will give another fluid challenge and ensure the critical care team is aware of the patient. I would also ensure the patient has a working cannula and send basic bloods, including septic screening. I would also request an ECG for the patient and a lying and standing blood pressure to investigate orthostatic hypotension.
• Disability: I would check the patient’s blood glucose and capillary ketones, temperature, and do a focused neurological assessment that includes GCS. Specifically, if the GCS is less than 8 or if there is a focal neurological deficit, I would be concerned and investigate this further.
• Exposure: I would examine the patient’s abdomen and look for evidence of an intra-abdominal pathology. I would also observe for any rapidly spreading skin rashes that may indicate a subcutaneous or cutaneous infection.

Additional Question

At this point, interrupt the candidate and mention the following: The patient provides an additional symptom upon systems review and mentions that she had noticed dark tarry stools over the last week. Two weeks prior, she had been in intense pain due to the rheumatoid flare and had taken a lot of ibuprofen throughout the day. She has also been feeling very tired throughout the day. Her observations are as follows: BP 100/60, HR 110, RR 18/min, SpO₂ 96% on air. Her ABG is mostly normal apart from her Hb which is 90. How would you proceed?

Answer

Based on the available clinical evidence, I believe that the patient may be having an upper GI bleed secondary to the NSAID usage that may be causing her dizziness and fatigue.

• I would admit the patient and do a Glasgow Blatchford score, which could be high in this patient.
• I would aim to ensure that the patient is adequately hydrated and has her blood checked at least twice a day to monitor blood counts. If the hemoglobin at any point drops below 80, I would initiate a restrictive transfusion for this patient.
• I will also ensure that the patient’s clotting and liver function are checked along with a group and save sample.
• I would refer the patient to the endoscopy team and ensure that the patient is handed over to be monitored closely.
• I will make my seniors aware of the patient, and if at any point, she were to clinically get worse, we would need to alert the on-call endoscopist for an urgent endoscopy.
• Post-endoscopy, I would be guided by the gastroenterologist regarding IV PPI therapy and its duration.
• I will also ensure that the patient is not prescribed any NSAIDs on her present drug chart.