Upper GI Bleed & Hematemesis


HISTORY_LIST
duration
quantity of blood
bright red blood
coffee grounds blood
vomiting prior to blood
abdominal pain
melena
hematochezia
ingestion of alcohol
ingestion of aspirin
ingestion of NSAID
ingestion of steroids
ingestion of potassium supplements
ingestion of anticoagulants
ingestion of quinidine
ingestion of iron
ingestion of tetracycline
ingestion of dipyridamole
nose bleed
syncope
light headedness
nausea
diaphoresis
CHRONIC DISEASE 
SYSTEMIC DISORDERS
ulcers
esophagitis
bleeding disorders
liver dz.
renal dz.
SURGERY
PREVIOUS HOSPITALIZATIONS
abdominal surgery
aortic surgery
PREVIOUS TESTS
recent hematocrit
X-rays
endoscopy
nasogastric aspiration
TRAUMA OR INJURIES
abdominal trauma
chest trauma
SOCIAL HISTORY
smoking
alcohol
caffeine
illicit drugs - cocaine
ALLERGY
medications
foods
seasonal
FAMILY HISTORY
blood disorders
liver dz.
alcoholism

MEDS_LAB_TESTS
**** MEDS
aspirin
NSAIDS
steroids
potassium supplements
anticoagulants
quinidine
iron
tetracycline
dipyridamole
**** LAB
Electrolytes
BUN (increased BUN suggest 
   upper GI bleed)
creatnine
CBC
LFT
Cr
glucose
PT/PTT
bleeding time
**** TESTS
ECG
EGD
bronchscopy
abdominal CT or MRI


REVIEW_OF_SYSTEMS_1
GENERAL
weight changes
appetite changes
anorexia
difficulty sleeping
fever
chills
polyphagia
hypophagia
changes in thirst
sleeping habit change
bowel habit change
fatigue
hypertension
previous physical exams
SKIN
pigmentation changes
texture changes
lesions
eruptions
pruritis
easy bruising
easy bleeding
unusual hair loss
changes in hair distribution
skin masses
finger/toe nail change
rashes
hives
striae
skin atrophy
uremic frost
hirsutism
plethora
neurofibromatosis lesion
HEENT
head trauma
skull fractures
head masses
hearing loss
vertigo
chronic ear infection
ear discharge
ear pain
hearing aid use
loss of vision
recent change in vision
photophobia
diplopia (double vision)
glaucoma
exudates
dry eyes
eye pain
cataracts
eye surgery
itchy eyes
excessive tearing
corrective lenses
nose bleeds
chronic sinusitis
nasal fractures
nasal drainage
polyps
changes in sense of smell
edentulous (without teeth)
partial plate
full plate
recent dental work
oral lesions
tonsillitis
strep throat
tongue problems
voice changes
chronic hoarseness
chronic halitosis
NECK
neck masses
enlarged thyroid gland
brachial cleft cysts
neck injury

REVIEW_OF_SYSTEMS_2
CHEST
chronic coughing
sputum production
hemoptysis
wheezing
pneumonia
bronchitis
TB
TB exposure
SOB
SOB altered by position
edema
chest pains
pacemaker
HEART
MI
coronary artery disease
heart murmur
heart valve disease
left ventricular hypertrophy
mistral valve stenosis
pericarditis
palpitations
DOE
paroxysmal nocturnal dyspnea
orthopnea
edema
hypertension
rheumatic fever
cardiomyopathy
ectopic heart beats
arrhythmia
exercise intolerance
claudication
heart medications
ABDOMEN
abdominal pain
nausea
vomiting
diarrhea
constipation
hematochezia
hematemesis
hemorrhoids
GI x-rays
GI scopings
rectal bleeding
ulcers
bowel polyps
bowel incontinence
gall bladder disease
gall stones
hepatitis
cirrhosis
hepatomegaly
splenomegaly
GU
renal insufficiency
renal failure
dialysis
kidney stones
kidney disease
kidney cyst
flank pain
hematuria
pyuria
dysuria
chronic cystitis
nocturia
anuria
hesitancy
enuresis
change in urine color
prostatitis
epididymitis
scrotal problems
TURP
pain on intercourse
genital lesions
genital discharge

REVIEW_OF_SYSTEMS_3
OB/GYN
metorrhagia
menorrhagia
irregular menses
problems in pregnancy
use of contraception
breast masses
nipple discharge
breast skin changes
changes in axillary nodes
monthly breast exam
breast feeding children
EXTREMITIES
difficulty with gait
weakness
joint swelling
joint stiffness
muscle pain
muscle swelling
muscle injuries
sagittal plan scoliosis
coronal plane scoliosis
fractured bones
SLE
osteoarthritis
rheumatoid arthritis
fibromyalgia
NEURO
seizures
head injury
LOC
loss of coordination
difficulty in balance
sciatica
difficulty in fine motor skills
difficulty speaking
CVA (stroke)
weakness in arms
weakness in legs
tingling in legs and feet
tingling in arms
PSYCHIATRIC
depression
bipolar disorder
suicide attempts
hospitalization for 
   psychiatric problems
personality disorders
ENDOCRINE
goiter
exophthalmos
dry skin
dry hair
intolerance to heat
intolerance to cold
changes in growth
sterility
impotence
decreased libido
LYMPHATIC AND HEMATOLOGICAL
lymphadenopathy
transfusion
anemia



PHYSICAL_EVAL_1
VITALS
BP
Supine Pulse
Upright Pulse
Temp
Heart rate
GENERAL
pallor
diaphoresis
cold, clammy extremities
agitation
confusion
SKIN
delayed capillary refill
pallor
petechiae
ecchymosis
umbilical venous collaterals 
   (caput medusae)
jaundice
spider angiomas
hemorrhagic telangiectasia 
    (Osler-Weber-Rendu syndrome)
pigmentation 
    (Peutz-Jeghers syndrome)
purple brown nodules 
    (visceral Kaposi's sarcoma)
HEENT
parotid gland hypertrophy
scleral pallor
oral telangiectasia
NECK
flat neck veins

PHYSICAL_EVAL_2
CHEST
gynecomastia in males
breast masses
ABDOMEN
scars
bowel sounds
tenderness
rebound
masses
splenomegaly
increased liver span
hepatomegaly
liver nodules
ascites
bruits
dilated abdominal veins
GU
gross blood
guaiac positive (occult blood)
masses
testicular atrophy
EXTREMITIES
Dupuytren's contractures
edema
bone pain
NEURO
mental status
confusion
memory
asterixis (flapping with 
   wrists hyperextended)




DIFF_DIAGNOSIS
gastric or duodenal ulcer
gastritis
esophagitis
esophageal varices
Mallory Weiss tear 
  (gastroesophageal junction 
  tear due to vomiting or retching)
swallowed blood 
    (nose bleed or oral lesion)
esophageal or gastric malignancy
vascular ectasias
duodenitis
coagulopathy
hypertrophic gastropathy 
    (Menetrier's dz.)
aorto-enteric fistula
telangiectasias 
    (Osler-Weber-Rendu syndrome)
pigmentation 
    (Peutz-Jeghers syndrome)
purple brown nodules 
    (visceral Kaposi's sarcoma)
connective tissue dz.
vasculitis
hematobilia
STIGMATA OF LIVER DISEASE
umbilical venous collaterals 
    (caput medusae)
jaundice
spider angiomas
parotid gland hypertrophy
gynecomastia


