Mr. S. is a 50-year-old man. He is the CEO of a large real estate company

Mr. S. is a 50-year-old man. He is the CEO of a large real estate company. He lives with his wife in an upscale suburban neighborhood outside of Toronto. His job is very stressful and he deals with this by drinking 2 or 3 bottles of beer, and several glasses of wine each evening. Frequently, he has business lunches where several alcoholic drinks may be consumed, however he never appears to be impaired during business hours. He states he feels he has balanced his responsibilities quite well, but his lifestyle does not allow him to fully abstain from drinking.
Unfortunately, his cirrhotic liver has never fully recovered from 25 years of heavy drinking. Although he has been diagnosed with cirrhosis, he has not been compliant with follow-up visits to his health care provider. 
Past Medical History:  Admitted to the hospital four times in the past 24 months, with a diagnosis of G.I. bleed. He has a 30-year history of smoking. 
Current/present situation
He states he has been coughing on and off for the past several days. His wife informs that this morning he coughed up “bright red blood” but he was quite irritable and refused to come to the hospital. His wife did call 911 earlier this evening when he began vomiting large amounts of bright red blood. He is admitted to your medical floor. 
On initial assessment you note that he is awake, alert, and answers questions appropriately. His vital signs are 114/66, 84, 97 R/A and remain within normal range from those recorded earlier in emergency.  You observe that he is jaundiced, has gynecomastia, and multiple ecchymotic areas on his body. The site for the maintenance IV has fresh bloodstains noted on the dressing. 
Later in the same shift, as you are doing rounds, his wife comes out of the room distraught.  You quickly enter his room and observe a large amount of blood all over his gown and bed linen. He looks terrified, appears confused and states I feel nauseated and dizzy. Vital signs at this time are: B/P 86/54, HR 122, SpO2 95 room air. 
Physical Exam Findings at this time: 
Neurological:  awake, alert, orientated to time, but not to place, irritable and confused.
HEENT:  Epistaxis noted; Yellow sclera
Respiratory: lung lobes clear bilaterally, breath sounds diminished to bases, complaining of shortness of breath
Cardiac:  normal S1 S2, no S3 or S4.  Heart rhythm regular, Pulse weak HR 122.  BP 86/54 mmHg, feels fatigued & lethargic
Abdomen: abdomen firm and distended, bowel sounds hyperactive to 4 quadrants, abdominal discomfort, vomiting large amounts of bright red blood
GU:  normal urinary output, gynecomastia
MSK:  some mild tremors in both hands
Skin:  pale, jaundiced, multiple ecchymotic areas on his body
Lab values:

-Hemoglobin 70 mmol/L (normal for males: 140 – 180 mmol/L)
-Hematocrit 0.27
-AST 260 u/L (normal: 0 – 35 u/L)
-Ammonia level of 117 mcmol/L, (normal: 6 – 47 mcmol/L)
-INR 3 (INR 0.81- 1.2)  
Treatment on initial admission (prior to bleed)

-Packed RBCs to be infused 2Units over 2 hours each
-PIV insertion 
-IV fluid 0.9 Nacl at 25mls/hr
-Albumin 25% 5g to be infused after RBCs completed
-Oxygen was administered at 3 liters per minute by nasal cannula. 
-Ɓeta adrenergic blocker
-Sclerotherapy for bleeding varices

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