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IM15.1-18 | GI Bleeding — Assignment

CLINICAL SCENARIO

This assignment requires you to construct a comprehensive structured clinical report for a patient presenting with acute gastrointestinal bleeding. You are given a clinical vignette and asked to work through the patient's evaluation, risk stratification, investigation selection, and management plan in sequential sections. The report tests constructive alignment between the clinical skills, investigative reasoning, and management knowledge developed throughout the GI Bleeding module. Your response must reflect final-year clinical competence and demonstrate accurate use of validated scoring systems, evidence-based transfusion thresholds, and disease-specific pharmacotherapy.

Instructions

The following clinical vignette underpins all six sections of your report. Read it before beginning.

VIGNETTE: Mr Ramesh Kumar, a 54-year-old retired schoolteacher from Puducherry, presents to the General Medicine emergency at 11 PM with two episodes of haematemesis (estimated 400 mL total) and melaena stools since the previous evening. He takes diclofenac 50 mg BD for knee osteoarthritis and aspirin 75 mg daily for a previous NSTEMI. He drinks alcohol socially (approximately 2-3 units per week). On examination: he appears pale and anxious; BP 98/62 mmHg supine; BP on standing 76/50 mmHg (postural drop 22 mmHg systolic); pulse 118/min; capillary refill 3 seconds; no spider naevi, no palmar erythema, no ascites, no splenomegaly. Abdominal examination shows mild epigastric tenderness. Rectal examination: melaena confirmed. Laboratory: Hb 8.2 g/dL; platelets 212 × 10^9/L; INR 1.1; BUN 38 mg/dL; creatinine 0.85 mg/dL; ALT 38 U/L; bilirubin 14 micromol/L; albumin 38 g/L. Rapid urease test for H. pylori: positive. Endoscopy (performed at 4 hours): 1.2 cm duodenal ulcer, posterior wall, with a non-bleeding visible vessel (Forrest IIa). Endoscopic haemostasis achieved with epinephrine injection and haemoclip application.

Work through all six sections in order. Use correct medical terminology throughout. Word limit: 1,200-1,600 words. Do not reproduce vignette text verbatim — integrate the clinical data into your reasoning.

Length: 1,200-1,600 words across all six sections

What to Submit

Section 1: Characterising the Bleed — Upper vs Lower GI and Aetiology

Guidance: Read the vignette carefully. Using the patient's symptom type (haematemesis, melaena, haematochezia), the BUN:creatinine ratio, and the examination findings, determine whether this is an upper or lower GI bleed. State the two commonest causes for the identified source in this clinical context. List two additional differential diagnoses with a one-line distinguishing feature for each. Approximately 200 words.

Section 2: Volume Assessment and Risk Stratification

Guidance: From the given vitals and clinical findings, classify the haemorrhagic shock class using the standard four-class system (state the volume loss range and key clinical criteria). Calculate the Glasgow-Blatchford Score from the data provided — show each component scored. Identify the single most important bedside clinical sign for volume assessment, explaining its threshold and physiological basis. Explain why the initial haematocrit may be misleading in the first 4-6 hours of acute haemorrhage. Approximately 250 words.

Section 3: Investigation Selection and Interpretation

Guidance: List the first-line laboratory investigations ordered at IV cannula insertion — state the purpose of each investigation, not just its name. Interpret the key laboratory finding given (BUN:creatinine ratio). State the indications for urgent versus early endoscopy. Describe the Forrest classification lesion found at endoscopy in the vignette and state its rebleed risk and management implication. Approximately 250 words.

Section 4: Treatment Plan

Guidance: Write a sequenced, time-stamped management plan appropriate to the identified aetiology (variceal or non-variceal). For variceal: include all four bundle components with drug names, doses, and timing. For non-variceal: include IV PPI regimen, H. pylori eradication protocol, and NSAID management. In both pathways: state the transfusion threshold with the specific haemoglobin level (and the modified threshold for cardiovascular disease). Approximately 350 words.

Section 5: Specialist Escalation and Patient Counselling

Guidance: State the specific clinical criteria that would trigger gastroenterology or surgical referral. Summarise, using plain language, how you would counsel the patient and one family member about the diagnosis, the planned treatment, expected hospitalisation, and lifestyle modifications needed after discharge. Demonstrate empathetic framing — acknowledge anxiety, avoid jargon, and invite questions. Approximately 200 words.

Section 6: Clinical Documentation

Guidance: Write a brief structured progress note (as you would enter in a hospital medical record) summarising the patient's presentation, assessment, and your management plan for the next 24 hours. Use standard medical notation. State the rationale for each major clinical decision. Avoid phrases such as 'managed conservatively' without specifying what was done. Approximately 150 words.

Grading Rubric — GI Bleeding Clinical Management Report Rubric

Criterion	Points	Full-marks descriptor
Clinical Characterisation and Upper vs Lower GI Differentiation (Section 1): Correctly identifies the anatomical source of bleeding using all three discriminators — clinical presentation, BUN:creatinine ratio, and examination findings. Precisely names the two commonest causes for the identified source and two relevant aetiological differentials.	15 pts	All three discriminators correctly applied; anatomical source correctly identified; two commonest causes named and one diagnostic distinguishing feature given for each; two differentials listed with brief rationale.
Volume Assessment and Risk Stratification (Section 2): Accurately classifies haemorrhagic shock using clinical parameters; correctly calculates and interprets the Glasgow-Blatchford Score from the given data; identifies the single most important bedside clinical sign for volume assessment; articulates why the haematocrit may be misleading in the first 4-6 hours.	20 pts	Shock class correctly identified with correct criteria; Glasgow-Blatchford Score correctly calculated from given parameters with interpretation; postural BP named as most informative bedside sign with explanation; haematocrit early limitation explained correctly with physiological mechanism.
Investigation Selection and Interpretation (Section 3): Selects the correct first-line laboratory and endoscopic investigations with clear justification for each; correctly states the Forrest classification finding given and its management implication; accurately names the indications for urgent versus elective endoscopy.	20 pts	All first-line investigations selected with clear purpose for each (CBC, coagulation, U&E, group-and-screen, LFT); BUN:creatinine ratio explicitly interpreted; Forrest classification stated correctly with endoscopic management implication; endoscopy timing criteria (within 24 hours for stable, within 12 hours for unstable) correctly stated.
Treatment Plan: Variceal or Non-Variceal Pathway (Section 4): Produces a complete, correctly sequenced treatment plan appropriate to the identified aetiology; for variceal: four-component bundle (vasoactive drug with correct agent and dose, EVL, antibiotics, restrictive transfusion); for non-variceal: IV PPI regimen, H. pylori eradication plan, and NSAID/aspirin management; correctly states restrictive transfusion threshold with distinction for CVD.	25 pts	Complete, correctly sequenced management plan for the identified pathway; correct vasoactive drug with dose and timing (terlipressin 2 mg IV q4h OR octreotide 50 mcg bolus + infusion), or IV PPI dose (omeprazole 80 mg bolus + 8 mg/hr for 72 hrs); antibiotics named correctly; H. pylori eradication regimen correct (triple/quadruple); transfusion threshold explicitly stated (Hb <7, or <8 in CVD); all four variceal bundle components present if variceal pathway.
Specialist Escalation and Patient Counselling (Section 5): Identifies the correct threshold for specialist referral (surgeon, gastroenterologist) with specific criteria; demonstrates understanding of how to counsel a patient and family about the diagnosis, treatment options, and prognosis using empathetic non-judgmental language.	15 pts	Specific escalation criteria named (failed endoscopic haemostasis, rebleeding after second attempt, haemodynamic instability refractory to resuscitation, Forrest Ia posterior ulcer risk of GDA involvement); counselling summary demonstrates understanding of plain-language explanation, acknowledgement of patient anxiety, and key information (diagnosis, treatment options, expected hospital stay, dietary/lifestyle advice).
Documentation and Professional Standards (Section 6): Demonstrates clear, structured clinical documentation of the management plan suitable for a medical record; uses correct medical terminology; avoids vague language; documents rationale for transfusion, pharmacotherapy choices, and specialist consultation.	5 pts	Documentation is structured, uses correct clinical terminology throughout, avoids vague phrases ('patient was managed conservatively'), and explicitly records rationale for each major clinical decision.

PEER REVIEW

Review your peer's GI Bleeding Management Report using the rubric provided. For each section assign a score and write one specific comment explaining your rating — do not copy the rubric descriptor. Pay particular attention to: (1) whether the Glasgow-Blatchford Score was correctly calculated from the vignette data; (2) whether the transfusion threshold is stated with the specific haemoglobin level; (3) whether the Forrest classification is correctly named and the management implication is explicitly stated; (4) whether the H. pylori eradication regimen is correctly detailed (drug names + duration). Complete your review within 72 hours of receiving the submission.