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A 62-year-old man presents to the emergency room with sudden onset of abdominal discomfort and passage of several large, black, tarry stools. He became diaphoretic and began to experience chest pain, similar to that of his recent myocardial infarction. Three weeks ago, he suffered an uncomplicated non-ST elevation myocardial infarction. A submaximal exercise treadmill test performed prior to discharge revealed no ischemia. He was discharged home with aspirin, clopidogrel, and metoprolol. On examination, his heart rate is 104 bpm. His blood pressure is 124/92 mm Hg while lying down but drops to 95/70 mm Hg upon standing. He appears pale and uncomfortable, and he is covered with a fine layer of sweat. His neck veins are flat, his chest is clear to auscultation, and his heart rhythm is tachycardic but regular, with a soft systolic murmur at the right sternal border and an S4 gallop. His apical impulse is focal and nondisplaced. His abdomen is soft with active bowel sounds and mild epigastric tenderness, but no guarding or rebound tenderness, and no masses or organomegaly are appreciated. Rectal examination shows black, sticky stool, which is strongly positive for occult blood. His hemoglobin level is 5.9 g/dL, prothrombin time (PT) and partial thromboplastin time (PTT) both are normal, and he has normal renal function and liver function tests. ECG reveals sinus tachycardia with no ST-segment changes, but T-wave inversion in the anterior precordial leads and no ventricular ectopy. Creatine kinase is 127 with a normal CK-MB (myocardial) fraction, and troponin I and serum myoglobin levels are normal.
♦ What is the most likely diagnosis?
ANSWERS TO CASE 57: Transfusion Medicine
Summary: A man with a recent myocardial infarction hut a negative postinfarction stress test, signifying no critical coronary artery stenosis, is admitted with angina pectoris at rest and ECG changes consistent with recurrent cardiac ischemia. In addition, he has melena and epigastric tenderness, indicating an upper gastrointestinal (GI) hemorrhage, likely caused by his use of aspirin. He is tachycardie and has orthostatic hypotension, indicating significant hypovolemia as a result of blood loss.
^ Most likely diagnosis: Unstable angina, which has been precipitated by anemia because of acute GI blood loss.
^ Next step: Transfusion with packed red blood cells (PRBCs).
1. Understand the indications for transfusion of red blood cells.
2. Know the complications of transfusions.
3. Be aware of alternatives to transfusion.
4. Know the indications for transfusion of platelets and of fresh-frozen plasma (FFP).
This patient has two urgent problems. He has suffered an upper GI hemorrhage. with enough blood loss to cause hemodynamic compromise. In addition. he has unstable angina, given his severe prolonged chest pain at rest but lack of definitive ECG or cardiac enzyme evidence of myocardial infarction. Rather than being a primary problem with his coronary arteries, such as thrombosis or vasospasm, the cardiac ischemia is secondary to his acute blood loss and consequent tachycardia and loss of hemoglobin and its oxygen-carrying capacity. He should be treated with urgent replacement of blood volume.
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