Upper GI bleeding - SimMan

Question

You are the FY 2 doctor in the A& E department.

Mr Alex ..60 year man brought in by his wife to A& E department because he is feeling dizzy
and feeling faint. Assess and discuss further management with him.

SimMan and Nurse is present inside the cubicle. Wife is not present inside the cubicle.

Talk to the nurse first.

Dr: Hello, I am Dr... May I know your name please? Can you please tell me about this patient
?
Nurse : Hello Doctor, I am Hawkins we have a patient here Mr Alex brought in by his wife, I
have attached the monitors, please look at the patient. 
Dr: Do you know why he was brought in ?
Nurse : He has some problems. You can talk to him doctor.

Look at the monitor – vitals may be stable/ fluctuating ( keep looking at the monitor)

Then talk to the patient.

Dr: Hello Mr. Alex .. I am Dr.... How can I help you ?
Pt: Doctor I am having dizziness, feeling faint.
Dr: Since when ? Pt: since last 3 days.

Dr: When do you feel dizzy Pt: when I walk for some time.
Dr: How is it now ? Pt: It is getting worse.
Dr: Anything else other than dizziness ? Pt: Like what ?
Dr: Did you lose consciousness ? Pt: No but I feel like I am going to faint.
Dr: Do you chest pain ? Pt: No I feel some discomfort in my chest.
Dr: What do you mean by discomfort ? can you please describe ? I can’t describe – I feel it
all over my chest.
Dr: Any Shortness of breath ? Yes/ no
Dr: Do you feel your heart beating fast or slow ( palpitation) ? yes/no

Dr: Do you have any headache ? No Dr: Any weakness in your arms or legs ( TIA) ? No
Dr: Any earache ? No Dr: Any balance problem ? No
Dr: Do you have pain in your tummy ? No
Dr: Any change in your bowel habits ? Dr: Any loose stools? Yes/no
Dr: Any bleeding from your back passage ? Yes/ No
Dr: What is the colour of your stool ? Pt: Normal/ Dark colour ? I didn’t look my stool
recently.

Past history
Dr: Did you have this problem before ? No
Dr: Did you have any medical conditions or did you have any medical conditions previously
I have Osteoarthritis - knee joint pain.
Dr: Do you take any medications for that ? Yes/No painkillers
Dr: Which one ? Diclofenac. Who gave that ( prescribed doctor or over the counter) ?
Dr: How long have been taking this medication ? For many months.
Any other medications ( PPIs, Steroids, Blood thinners) ? No
Dr: Do you have bleeding from anywhere like – urine, nose, gums ? No
Dr: Do you have any bleeding disorders ? No

Dr: Any heart problems ? No HTN ? No DM ? No

Dr: Do you have any allergies ? No

Patient says – I soiled myself now doctor/ I am dying doctor.

Dr: I see. Don’t worry. You are in safe place. I need to examine you.
Check the monitor again – Blood drops to 90/60, Pulse – very high. Low oxygen saturation.
Ask nurse to give IV fluid immediately
Hartman’s – one litre bolus within 10 min. Use 2 large bore cannulae
( Grey colour – 16G ) in 2 arms;
Give Oxygen ( mask may be present put on the manikin)
Nurse will put cannula on the arm. Examiner says assume she has given fluid.
Check the monitor again.
Blood pressure picks up and Oxygen saturation improves.
Ask patient are you feeling better ? Yes doctor.

Dr: need to examine your chest and tummy. Can you please undress?
Doctor you do it. Remove his hospital gown.
Examine chest
Inspection - chest appears normal on inspection. Movements symmetrical. Auscultation –
normal.
Examine abdomen – Inspection, palpation percussion auscultation normal.
Remove inners – Maleana – dark stool visible. ( if he denied about taking any
medication before ask it again – any over the counter medication – then he may say yes
I am taking diclofenac)

Cover him

Diagnosis:

I can see have passed dark loose stool now. Looks like you have bleeding in your tummy. It
could be due to the Diclofenac medication what you are taking which causes damage to
stomach wall or ulcers in the stomach and causes bleeding in the stomach.

Further investigation and treatment.

Dr: We need to do some more blood tests – check for anaemia, blood group and cross match,
clotting tests. We need to give blood transfusion immediately. Is that Okay ? Yes doctor.
We will call the specialist doctor called Gastro-enterologist. They will do some test called
Endoscopy which is a camera test where they pass a tube with a camera at its tips through
your mouth to the food pipe and stomach. This will help to check where is the bleeding and
also it will help to stop the bleeding. We will also give some medication called PPIs.

Pt: Can I go home? Dr: No unfortunately this is very serious condition. We need to keep you
in the hospital and treat you.
Tell the nurse. Could please send the blood for the tests and keep monitoring the patient and
arrange for blood transfusion. I will inform my seniors and call the Gastro-enterologists come
immediately. Nurse – Okay doc
Thank the patient, nurse and the examiner.