1. Working Template Present case - Jay Clinical Approach (Hx, PE, definition of terms) Salient features/ Pivotal signs and symptoms Problems of the Patient Differentials - Clay Recapitulation of Differentials and clinical Impression after report of Groups A-C Management

2. Approach to a Patient with Upper GI Bleeding GI Module BGD # 1 June 21, 2009

3. Insert Case Presentation Slides from Jay and Serge

4. 5 Presentations of GI Bleeding Hematemesis – Vomitus of red blood or coffee-gorunds material Melena – Black, tarry, foul-smelling stool Hematochezia – Passage of bright red or marron blood from the rectum Occult GI bleeding – Identified in the absence of overt bleeding by a fecal occult blood test or the presence of iron deficiency Symptoms of Blood loss or anemia – Lightheadedness, syncope, angina, dyspnea Harrison’s Internal Medicine, 17 th edition

5. Clinical approach to a Patient with GIB Assessment and resuscitation to stabilize the patient History and PE – Assess magnitude of hemorrhage – Chronic vs acute Differentiate Upper GIB from Lower GIB Diagnostic Evaluation: Endoscopy Therapy Harrison’s Internal Medicine, 17 th edition

6. Upper vs Lower GI Bleeding Upper GIBLower GIB Hematemesis Melena Hyperactive bowel sounds Elevated BUN Hematochezia Harrison’s Internal Medicine, 17 th edition

7. Differentiating Upper from Lower GIB

8. Approach to the Patient with Upper GIB GASTROENTEROLOGY an illustrated colour text by Graham P. Butcher, MD; 2003

9. Sources of Upper GI Bleeding Harrison’s Internal Medicine, 17 th ed Common CausesLess Common Ulcers Mallory-Weiss tears Ruptured Esophageal Varices Gastroduodenal Erosions/ Gastritis Erosive esophagitis Neoplasm Vascular ectasias Unknown origin GASTROENTEROLOGY an illustrated colour text byGraham P. Butcher, MD; 2003 CommonLess Common Duodenal Ulcer Gastric Ulcer Mallory-weis s tears Esophageal varices Gastric erosions Duodenitis Esophagitis Tumors Hereditary Telangiectasia Aortoduodenal fistulas Clotting disorders Portal Hypertensive gastropathy Dieulafoy lesions

10. Salient Features (Subjective) Pertinent PositivePertinent Negative 65 yo female Melena Hematemesis Cold clammy sweats and dizziness 10kg weight loss for the past 6months Use of Diclofenac Na

11. Salient Features (Objective) Pertinent PositivePertinent Negative Orthostatic hypotension Tachypnea Tachycardia Hyperactive bowel sounds Pale palpebral conjunctivae Maroon colored stools shown in DRE No fever Anicteric sclera No cervical lymphadenopathy Lung and heart sounds normal No tenderness, palpable masses or organomegaly upon abdominal PE

12. Differential Diagnosis Insert list of differentials Report of Groups A-C

13. Differential Diagnosis PUDNSAID gastropathyGastric Cancer Burning, intermittent epigastric pain Relieved by food intake Exacerbated during night time Chronic NSAID useFever Palpable Mass Node enlargement

14. Clinical Impression Upper GIB secondary to PUD brought about by chronic NSAID use

15. Rationale