It is 3 a.m. on a cold winter morning. You were transporting patients until 1 a.m. and you were just starting to get some quality sleep when the tones go off. You have been busy transporting patients with nausea and vomiting and feel as though you are probably catching the same flu. You are less than enthusiastic about this call—yet another nausea and vomiting complaint.

You arrive on scene in an affluent part of town, where you are met at the door by a 40-year-old male who states he is the patient’s son. He reports he has just arrived from out of town and has discovered his father is quite ill. The son says he would have called you sooner but he had difficulty convincing his father to seek help. He reports his father has been nauseated and vomiting and the emesis is now bright red in colour. He says his father does not look good.

You find a 65-year-old male patient sitting on the floor in the bathroom. He is retching as you enter the room and the toilet is full of bright red emesis. He appears tired and lethargic. He is aware of your presence but makes no attempt to get up or to clean himself. From a distance his skin looks pale. He does speak to you and is aware of person, place, time and situation. He is, however, slow to answer your questions. He has control of his airway, his respirations are deep, regular and laboured. He continues to spit blood into the toilet. He reports he feels short of breath. His pulses are present and equal at the neck and the wrist but are fast, irregular and weak. His neck veins are flat, trachea is mid-line. There are no signs of trauma anywhere on the patient and he denies any mechanism of trauma. His chest is unremarkable in appearance or on palpation. Lung sounds are present throughout with no adventitious sounds.

His abdomen appears distended and tender. It is rigid in the RUQ and the patient reports even more pain there on palpation. Sensation is present in the lower and upper extremities but motor movement is weak. His skin is pale with cyanosis about the lips. He feels cool and clammy. His sclera are yellow and his conjunctiva are pale with a yellowish tinge. The patient reports he has been drinking off and on for the past week and has a history of alcoholism. He reports he started vomiting yesterday but the blood has only appeared in the emesis over the past two hours and it is the presence of this blood that has caused him to phone for an ambulance. He states that for two weeks he has been passing dark tarry stools and has been generally feeling unwell. He has had the abdominal pain for approximately two weeks as well. As well as alcoholism, he has a medical history of cirrhosis. He denies any other medical history. He is on no medications at present but he has been taking aspirin on a regular basis over the past two weeks in an attempt to control the abdominal pain. He has been on a liquid diet of alcohol over the past two weeks and has been unable to keep any food down. There is an odor of alcohol on his breath but his behavior is not consistent with intoxication. He does not visit a doctor on a regular basis and has not seen a physician for over a year.

1.The most appropriate tentative diagnosis for this patient would be:A. Intestinal obstructionB. Esophageal varicesC. FluD. Aneurysm

2.This patient’s vital signs are most indicative of:A. Hypovolemic shockB.  Septic shockC. InflammationD. Pain/anxiety

3.The organ most likely responsible for this patient’s tender, rigid, RUQ is:A. BladderB. KidneyC. SpleenD. Liver

4.Treatment goals for this patient should be aimed at:A. Stopping the bleedB.  Stopping the vomitingC.  Supporting vital signs and increasing perfusionD. All of the aboveE. None of the above