GI bleeding

The diagnosis of upper GI bleeding is assumed when hematemesis is documented. In the absence of hematemesis, an upper source for GI bleeding is likely in the presence of at least two factors among: black stool, age < 50 years, and blood urea nitrogen/creatinine ratio 30 or more. In the absence of these findings, consider a nasogastric aspirate to determine the source of bleeding. If the aspirate is positive, an upper GI bleed is greater than 50%, but not high enough to be certain. If the aspirate is negative, the source of a GI bleed is likely lower. The accuracy of the aspirate is improved by using the Gastroccult test.About 75% of patients presenting to the emergency room with GI bleeding have an upper source. The diagnosis is easier when the patient has hematemesis. In the absence of hematemesis, 40% to 50% of patients in the emergency room with GI bleeding have an upper source . Determining whether a patient truly has an upper GI bleed versus lower gastrointestinal bleeding is difficult.In a study published regarding a new scoring system called the Glasgow-Blatchford bleeding score, 16% of patients presenting with upper GI bleed had GBS score of "0", considered low. Among these patients there were no deaths or interventions needed and the patients were able to be effectively treated in an outpatient setting.
Score is equal to "0" if the following are all present:

Hemoglobin level >12.9 g/dL (men) or >11.9 g/dL (women)
Systolic blood pressure >109 mm Hg
Pulse <100/minute
Blood urea nitrogen level <18.2 mg/dL
No melena or syncope
No past or present liver disease or heart failure
AMI
In up to one-half of cases, a precipitating factor appears to be present before STEMI, such as vigorous physical exercise, emotional stress, or a medical or surgical illness. Although STEMI may commence at any time of the day or night.
Pain is the most common presenting complaint in patients with STEMI. The pain is deep and visceral; adjectives commonly used to describe it are heavy, squeezing, and crushing, although occasionally it is described as stabbing or burningTypically the pain involves the central portion of the chest and/or the epigastrium, and on occasion it radiates to the arms. Less common sites of radiation include the abdomen, back, lower jaw, and neck. The frequent location of the pain beneath the xiphoid and epigastrium and the patients' denial that they may be suffering a heart attack are chiefly responsible for the common mistaken impression of indigestion.
Other less common presentations, with or without pain, include sudden loss of consciousness, a confusional state, a sensation of profound weakness, the appearance of an arrhythmia, evidence of peripheral embolism, or merely an unexplained drop in arterial pressure.The combination of substernal chest pain persisting for >30 min and diaphoresis strongly suggests STEMI. Although many patients have a normal pulse rate and blood pressure within the first hour of STEMI, about one-fourth of patients with anterior infarction have manifestations of sympathetic nervous system hyperactivity (tachycardia and/or hypertension), and up to one-half with inferior infarction show evidence of parasympathetic hyperactivity (bradycardia and/or hypotension).