Melena
Age: years old
Gender:
HISTORY:
Presents with a - history of melena
Described as , stools,
Occurred times
Associated symptoms: *Try using right-click for negatives*
, , ,
, episodes , ,
, , , ,
, over ,
Contributing factors:
no history of: ,
no use of: , , ,
no family history of:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , , , bowel sounds , ,
Anorectal: DRE , prostate , , , anus
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
DDx: upper gastrointestinal bleeding, lower gastrointestinal bleeding, peptic ulcer disease, gastric erosions, gastric cancer, esophageal varices, Mallory-Weiss tear, duodenal ulcer, angiodysplasia, Dieulafoy's lesion, medication-induced gastrointestinal bleeding (e.g., NSAIDs, anticoagulants), coagulopathy, inflammatory bowel disease, intestinal ischemia, right-sided colon cancer, Meckel's diverticulum, iron supplement, blueberry intake, aortoenteric fistula, infectious enterocolitis, radiation enteritis, vascular malformations, diverticulosis
PLAN:
Investigations:
- Blood work: , , , , , , ,
- H. pylori breath test
- Upper GI endoscopy
- Colonoscopy
- Abdominal ultrasound
- CT scan of abdomen and pelvis
Treatments:
- IV fluids
-
-
- Stop NSAIDs
- Stop anticoagulants
- Increase fluid intake
Further care:
- Referral to gastroenterologist
- Referral to general surgeon
- Follow-up in
- Return if bleeding worsens, if new symptoms develop such as abdominal pain or weight loss, or if symptoms do not improve with treatment
- Referral to ER if severe abdominal pain, fever, or hemodynamic instability occurs
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: