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Answers on p 447.
A 76 year old white man was admitted to the intensive care unit with a one day history of confusion, altered mental status, and a three day history of nausea, vomiting, and abdominal discomfort. On the day of admission he was initially taken to a local hospital where a nasogastric tube was placed and three litres of blood tinged aspirate was obtained. The patient was transferred to our facility for further care. His past medical history was significant for hypertension, peptic ulcer disease and long standing constipation for which he used 2–3 bottles per day of milk of magnesia. His other prescribed medications included amlodipine and vitamin supplements. He denied use of alcohol or illicit drugs. On examination he was afebrile, his blood pressure was 106/52, and pulse rate 93 beats/min. He was confused and disorientated to time and place. His abdomen was soft to palpation with hypoactive bowel sounds. There were no focal neurological signs. The remainder of the physical examination was unremarkable. His baseline and initial electrolytes are shown in table 1. Results of a liver function test and complete blood count were within normal limits.
- What additional history would help in making a diagnosis?
- What is the most likely explanation for the electrolyte disturbance?