Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Hematemesis (vomiting blood) – fresh red blood is more concerning for active bleeding.
Melena (black tarry stools) – indicates bleeding higher in the GI tract.
Coffee-ground emesis (vomiting dark brown material) – suggests prior bleeding.
Hematochezia (bright red blood in the stool) – suggests bleeding in the lower GI tract (less likely in this case).
Abdominal pain (may or may not be present).
History of Present Illness:
Onset, duration, and severity of bleeding.
Character of blood vomited or passed in stool (fresh red, dark, etc.).
Associated symptoms (abdominal pain, nausea, vomiting).
Risk factors for peptic ulcer disease (PUD)
NSAID use (current or recent)
H. pylori infection
Prior history of PUD
Smoking
Alcohol abuse
Other risk factors for UGI bleeding (eosinophilic esophagitis, malignancy)
Past Medical History:
Underlying medical conditions (e.g., peptic ulcer disease, esophagitis, gastritis, liver disease).
Prior surgeries (abdominal surgeries may increase risk of peptic ulcer disease).
Medication use (NSAIDs, anticoagulants, corticosteroids).
Social History:
Smoking history (increases risk of peptic ulcer disease).
Alcohol consumption (increases risk of gastritis and peptic ulcer disease).
Family History:
Not typically relevant for non-variceal UGI bleeding unless there is a familial predisposition to peptic ulcer disease.
Physical Exam:
General examination: Assess vital signs (check for signs of shock
if bleeding is severe – low blood pressure, rapid heart rate).
Abdominal examination: Palpate for abdominal tenderness or masses.
Laboratory Tests:
Complete blood count (CBC): May show anemia (low red blood cell
count) if bleeding is significant.
Blood type and Rh factor: Needed for potential blood transfusion.
Coagulation studies (PT/INR, PTT): May be abnormal if patient takes
anticoagulants or has liver dysfunction.
Serum electrolytes: May be deranged if there is significant blood loss
and dehydration.
Occult blood test (stool): May be positive even in upper GI bleeding
due to blood traveling down the digestive tract.
Upper Endoscopy (EGD):
Gold standard for diagnosis of the source of bleeding and potentially
therapeutic intervention (e.g., banding of bleeding ulcers).
Imaging Studies:
(May be used in specific situations):
Abdominal X-ray (limited role): May be used to rule out pneumoperitoneum
(air in the abdominal cavity) which can suggest perforation (a hole in
the GI tract).
Abdominal CT scan (rare): May be used if endoscopy is contraindicated
or inconclusive, or to assess for complications (perforation).
Assessment:
Non-variceal upper gastrointestinal (UGI) bleeding: Confirmed by
hematemesis, melena, or coffee-ground emesis, and endoscopy showing a non-variceal source of bleeding.
Probable source of bleeding: Based on endoscopic findings (e.g., peptic ulcer, gastritis, Mallory-Weiss tear).
Severity of bleeding: Based on clinical presentation (vital signs,
amount of blood loss) and laboratory findings (hemoglobin level).
Differential Diagnoses:
Consider other causes of hematemesis or melena:
Esophageal variceal bleeding (ruled out by endoscopy)
Mallory-Weiss tear (a tear in the esophagus from forceful vomiting)
Gastritis
Esophagitis
Plan:
The treatment plan depends on the source and severity of bleeding.
Possible elements include:
Intravenous fluids: Resuscitation with fluids to restore blood volume
and blood pressure.