What is the appropriate template for a history of present illness in a patient presenting with melena?

History of Present Illness Template for Melena

When documenting a patient presenting with melena, your HPI must immediately establish hemodynamic stability, quantify blood loss, identify high-risk features, and determine the likely bleeding source to guide urgent endoscopic evaluation within 24 hours. 1, 2

Chief Complaint

• Document exact description: "black, tarry, sticky stools with characteristic odor" (true melena is a clinical diagnosis) 2
• Confirm with digital rectal examination findings 2

Onset and Duration

• When did the melena start? (exact date/time) 1
• How many episodes? (quantify number of bowel movements with melena) 1
• Is this the first episode ever, or has this happened before? 2

Associated Symptoms (Critical for Risk Stratification)

• Hematemesis: Any vomiting of blood or coffee-ground material? (indicates active upper GI bleeding and higher severity) 1, 3
• Hematochezia: Any bright red blood per rectum? (massive upper GI bleeding can present this way if transit time is rapid) 1, 2
• Syncope or presyncope: Any lightheadedness, dizziness, or loss of consciousness? (suggests significant blood loss) 1
• Abdominal pain: Location, character, severity (peptic ulcer disease often causes epigastric pain) 1
• Dyspepsia or heartburn: Chronic symptoms suggest peptic ulcer or erosive disease 3

Hemodynamic Assessment (Document Immediately)

• Current vital signs: Heart rate, blood pressure (sitting and standing if stable) 1, 2
• Calculate shock index: HR/systolic BP (>1 indicates hemodynamic instability requiring ICU admission) 1, 2
• Orthostatic hypotension: Drop in systolic BP >20 mmHg or HR increase >20 bpm when standing (indicates significant blood loss) 2

Quantification of Blood Loss

• Estimated number of melenic stools in last 24 hours 1
• Volume of hematemesis if present (cupfuls, tablespoons) 3
• Symptoms of anemia: Fatigue, weakness, dyspnea on exertion, chest pain 1

High-Risk Features (Each Increases Mortality)

• Age >65 years (significantly higher mortality) 1, 2
• Comorbidities: Cardiovascular disease, renal disease, liver disease/cirrhosis, malignancy 1, 4
• Shock at presentation: Pulse >100 bpm, systolic BP <100 mmHg 1
• Active hematemesis with ongoing bleeding 1

Medication History (Critical for Etiology and Management)

• NSAIDs: Current or recent use, duration, dose (major risk factor for peptic ulcer disease) 1, 2
• Anticoagulation: Warfarin, DOACs, aspirin, clopidogrel (must be documented and held) 4, 2
• Antiplatelet agents: Aspirin, clopidogrel (withhold until bleeding controlled) 4
• Corticosteroids: Increase ulcer risk 1
• Proton pump inhibitors: Current use or recent discontinuation 1
• Iron supplements or bismuth: Can cause black stools that mimic melena (but lack tar-like consistency and odor) 1, 2

Past Medical History (Guides Differential Diagnosis)

• Prior GI bleeding: Previous episodes, diagnosed source, treatment 2
• Peptic ulcer disease: Known history, H. pylori status 1, 2
• Liver disease/cirrhosis: Portal hypertension and varices are common causes (33% of melena cases) 3
• Chronic kidney disease: Increases bleeding risk and angiodysplasia 2
• Cardiovascular disease: Affects transfusion thresholds (maintain Hgb >9 g/dL vs >7 g/dL) 1, 4
• Malignancy: Small bowel tumors in patients <50 years 2
• Prior abdominal surgery or radiation: Can cause small bowel sources 2

Social History

• Alcohol use: Quantity, duration (direct toxic effects on intestinal epithelium, increases peptic ulcer risk, suggests possible varices) 2, 3
• Tobacco use: Impairs ulcer healing 1

Review of Systems (To Exclude Other Bleeding Sources)

• No epistaxis, hemoptysis, or other bleeding (confirms GI source) 1
• Weight loss: Suggests malignancy 2
• Jaundice or ascites: Suggests liver disease and possible varices 3

Initial Laboratory Assessment to Document

• Hemoglobin level: Current value and 12-month nadir if available (Hgb <7 g/dL requires transfusion, <9 g/dL if cardiovascular disease) 1, 4, 5
• Transfusion requirements: Number of units needed indicates severity (≥4 units associated with 20% mortality) 4

Clinical Pitfalls to Avoid in Documentation

• Do not confuse simple black stools with true melena: True melena has distinctive tar-like consistency and odor; dietary iron or bismuth causes black stools without these features 1, 2
• Do not assume lower GI source: Melena typically indicates upper GI bleeding proximal to ligament of Treitz, but right colon can occasionally cause dark stools 1, 6
• Do not delay endoscopy for stool studies: Melena is a clinical diagnosis warranting immediate evaluation 2
• Document if patient is hemodynamically unstable despite resuscitation: This requires immediate CT angiography rather than waiting for endoscopy 2