Dr. Zachary Levine
Dr. Zachary Levine gives us the 911
THE CASE A 78- year- old woman arrives at the ER complaining of lethargy, light-headedness and a fall. She lives independently and is active. She takes medication for high blood pressure.
THE SYMPTOMS Over the last few days, she had been feeling weak and tired. Today, she felt light- headed and fell. She does not think that she lost consciousness. She had also been feeling short of breath on exertion. There was no chest pain but some upper abdominal burning, which she assumed was heartburn. At triage, the nurse took her vital signs: heart rate 95 (a bit high); blood pressure 102/75 (low/normal), oxygen saturation 95 per cent (borderline low) and temperature of 36.8 C (normal). There was no chest pain, cough, congestion, fever or chills. Her head and neck exam was normal, aside from looking pale. Her heart sounds were normal, aside from a slight murmur. Her lungs were clear. Her abdomen had normal sounds and was soft but with mild tenderness in the upper region. When she sat up after lying down, she felt lightheaded, and there was a drop in her blood pressure to 90/70 (called a postural drop) while her heart rate remained at 95.
THE TESTS The electrocardiogram was normal, showing no evidence of heart strain or previous heart damage. A computerized tomography ( CT) scan of the head, performed to rule out a brain bleed if she hit her head when she fell, was normal. Blood tests showed normal kidney function and electrolytes ( sodium, potassium, chloride, calcium, magnesium, phosphate). Troponin (heart enzyme) was normal, indicating no heart damage,aswere liver function tests and lipase (for pancreas function).
DIAGNOSIS The patient’s hemoglobin ( the protein in red blood cells that carries oxygen to the organs)wasverylowat65 (normal is 120 to 140), meaning she was anemic. Anemia can cause weakness, fatigue, shortness of breath and dizziness. The MCV (mean corpuscular volume) was low, indicating small red blood cells; iron testing revealed low iron levels. The most common cause of iron-deficiency anemia is blood loss, and the most common place to lose blood from is the gastrointestinal tract. When a patient has significant microcytic (small cells, low iron, usually from blood loss) anemia, the doctor should perform a rectal examination to see whether there is black or bloody stool. The patient’s stool was indeed black and was positive for blood.
THE TREATMENT The patient was given two units of blood to take the strain offffffff her body due to the anemia. Her vital signs normalized. Next, a gastroenterologist performed an endoscopy (with a fibre-optic camera) to look for a source of the bleeding. The black stool and upper abdominal discomfort pointed to the gastrointestinal tract. A gastroscopy was performed, and a gastric (stomach) ulcer was seen, oozing blood. A clip was put in to stop the bleeding, and the patient was started on an intravenous antacid medication.
THE OUTCOME The patient was admitted to the hospital for 48 hours. The biopsy from the ulcer grew H. pylori, a bacterium known to be one of the causes of stomach ulcers. Two weeks of antacid medications and antibiotics were prescribed, and the patient was instructed to stay offff anti-inflammatory medications. She had been taking these medications for a sprained ankle, but they can also lead to inflammation, ulcers and bleeding in the stomach. A repeat gastroscopy three months later showed that the ulcer had healed.