Questions for Discussion:

  1. What would be your initial management of this patient at this point?
  2. What are clues from the history and physical examination that suggest the location of the gastrointestinal bleeding?

A nasogastric tube is placed and the return reveals clear fluid.

The initial laboratory evaluation is as follows: Hgb-9.1 gm/dl, Hct-28%, WBC-13, 500 (normal differential) Platelets- 450,000, PT/INR/PTT-normal, BUN/Creatinine-45/1.7 mg/dl.

  1. What is a reasonable differential diagnosis for this patient?   Give reasons for your differential diagnosis and defend the most likely diagnosis.
  2. What diagnostic tests would you perform on this patient?

An upper GI endoscopy (EGD) is performed and revealed a 1.5 cm duodenal ulcer on the bulb with fresh clot adherent to the ulcer base and some oozing of blood from the edges of the clot.

  1. What is the significance of the nasogastric tube aspirate?
  2. How would you interpret the endoscopic findings?
  3. How would you manage this patient at this time?
  4. What additional aspects of this patient's health must be addressed before discharge?

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