I'm at a small clinic for my student internship. I'm lazily strolling through routine follow ups when a young woman walks in, accompanied by her boyfriend, complaining of severe light headedness, nausea and vomiting small amounts of frank blood since waking up. She had been vomiting daily (not blood) for the past week and gives a history of peptic ulcer disease, though she denies melena stools.
She's not pale, but obviously dehydrated. Pulse is over 100 and systolic is in the 90s so we can't rule out an upper GI bleed in addition to dehydration. We start a normal saline infusion and push 10mg metoclopramide IVI as we wait for an ambulance (we don't have the facilities to do a blood gas or urgent blood tests, let alone endoscopy).
On further history, she had hernia repair surgery two months ago, though she can't say which type. Abdominal exam reveals a ~5cm vertical scar above the umbilicus and mild epigastric tenderness. The rest of the exam is unremarkable, except that the patient seems a bit disinhibited, which we chalk up to dehydration and possible hemorrhage (she denied any substance use).
I happened to meet the paramedic who transferred the patient the next day. Turns out the Hb was normal, blood gas revealed high anion gap metabolic acidosis and toxicology screen was positive for propylene glycol. It wasn't clear yet whether this was a suicide attempt or a poisoning attempt.
This was a bizarre case overall with confounders all over the place. I'm still not sure what to think of it.
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