Clinical Summary

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The patient was a 74-year-old Caucasian man who was admitted to the hospital because of 4-month history of epigastric pain, weight loss of 11 kg and episodes of hematemesis and hemoptysis. The epigastric pain had an insidious onset, was dull, non-radiating, non-exertional, and was not associated with food intake. In addition, he experienced intermittent difficulty in swallowing for which he took antacids with some relief. He also described malaise, hyporexia and nausea. There was a history of hypertension treated with diuretics. The patient also complained about occasional dyspnea on exertion, mild ankle swelling and intermittent claudication. The latter symptoms had developed over a period of a few years, and the patient attributed them to his age. There was no history of rheumatic heart disease, coronary artery disease, gallbladder disease, pancreatitis, hepatitis, change in bowel habits, tuberculosis, bleeding diathesis, or trauma. Surgical history revealed a partial gastrectomy at age 54 for peptic ulcer disease. He drank alcohol socially, and smoked 1-2 PPD for as long as he could remember. He had a chronic productive cough with white sputum, and denied any recent change in the pattern of his cough. He had had multiple sexual partners during his lifetime.

Three months prior to admission, the patient described several episodes of bright red hemoptysis, for which he was admitted to the hospital. He was not certain whether these episodes represented hemoptysis or hematemesis. The physical examination at that time revealed a thin elderly male, appearing chronically ill and somewhat uncomfortable in bed. There was a grade II/VI decrescendo diastolic murmur best heard at the left base. The abdominal examination was unremarkable. There was mild bilateral pitting edema in the lower extremities. The rectal examination revealed no masses and a stool specimen was positive for occult blood. The white blood cell count was normal. The hemoglobin was 8.5 g/dL, and the glucose 136 mg/dL. The transaminases were minimally elevated. The bilirubin and amylase were within normal limits. A urine analysis was unremarkable. The chest-x-ray showed a slightly enlarged heart with a dilated aortic root. The electrocardiogram revealed a pattern compatible with left ventricular hypertrophy. Extensive work-up including GI series, celiac angiogram, and pancreatic scan did not uncover any specific lesion. He was discharged without a definitive diagnosis.

Three days after his release from the hospital, the patient again developed hemoptysis. Meanwhile, his epigastric pain had increased, and he had an overall deterioration of his health with increasing fatigue and anorexia. The temperature was 37°C rectally; pulse 108, respirations 22 and the blood pressure was 140/72 mmHg, without orthostatic changes. The neurologic and HEENT examination was unremarkable. There was no lymphadenopathy. The patient was non-icteric. The carotid pulse was 2+ bilaterally without bruits. The jugular venous pressure was estimated to be within normal limits. The chest was clear to percussion and auscultation. The cardiac examination revealed that the PMI was slightly displaced to the left laterally. Again, there was a grade II/VI diastolic decrescendo murmur that radiated to the left lower sternal border, which was best auscultated at the left base with the patient sitting up and leaning forward. The femoral and popliteal pulses were not palpable bilaterally; however, the pulses of the upper extremities were within normal limits. The abdomen was mildly distended with normal bowel sounds, there was no guarding, rebound tenderness or hepatosplenomegaly. The lower extremities were cool to the touch and had 1+ pitting edema. The rectal examination revealed no masses. A stool sample remained positive for occult blood.

Laboratory data and other tests

Laboratory: WBC 7.0, Hb/Hct 8.4/26, MCV 76, Plt 260 (peripheral blood smear confirmed a microcytic anemia, but was otherwise unremarkable); normal electrolytes, SGOT 48, protein T/A 6.5/3.2, bilirubin T 0.6, LD 378, BUN/creat 28/1.2, glucose 110. The urine analysis was unremarkable. ECG: normal PR and QRS intervals and left ventricular hypertrophy. The CXR showed a moderately enlarged heart with a dilated aortic root. An upright plain film of the abdomen revealed no free air.

While in the hospital, the patient had several more episodes of hemoptysis of about 50 cc each time and one episode of massive bleeding, bringing up an estimate of 1000-1500 cc of bright red blood. Meanwhile, a bronchoscopy failed to reveal any pathology. The bleeding episode recurred and a nasogastric tube was placed revealing fresh blood in the stomach. Irrigation with iced saline, transfusion of 6 units of blood and placement of a Sengstaken-Blakemore tube failed to control the bleeding. The patient was taken to the operating room for a laparotomy and the source of bleeding was located above the stomach. A thoracotomy was performed and a presumptive

diagnosis was made. The patient was placed on a partial cardiopulmonary bypass, but had a cardiac arrest and could not be resuscitated.

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