Quick answer
How should I present an upper GI bleed case on rounds?
Lead with the melena, its duration, and the orthostatic dizziness, since that symptom signals significant blood loss. Name the NSAID use directly, then give the hemoglobin, BUN-to-creatinine pattern, and INR before naming peptic ulcer disease as the likely cause. End with stopping the NSAID, resuscitation, and endoscopy timing, and what vital signs still need checking.
Before you speak
Define the moment and the information you actually have
An emergency-department presentation once the stat upper GI bleed labs are back, before endoscopy has been performed.
A supervising physician deciding on resuscitation and endoscopy timing.
History, medications, social history, and hemoglobin, BUN, creatinine, and INR. Vital signs, including orthostatic measurements, are not yet supplied.
About 80 seconds
Fictional training case: The presentation is locked to the simulated patient JSON. It names important unknowns instead of inventing an examination, vital signs, allergies, or tests.
Complete spoken example
First, read it once without stopping
The paragraph breaks show the clinical shape. In a real presentation, pause briefly between ideas rather than announcing the headings.
Mr. Nguyen is a 45-year-old man on daily NSAIDs for osteoarthritis who presents with two days of black, tarry stools and dizziness on standing.
He has had three episodes of melena over two days with mild epigastric discomfort but no vomited blood and no bright red rectal bleeding. He wonders if it could be from iron-rich food but is frightened it might be cancer.
He takes ibuprofen three times daily for six months for osteoarthritis and recently started omeprazole; he has no prior GI history, works as a chef, and drinks alcohol only occasionally.
His hemoglobin is 9.1, his blood urea nitrogen is elevated at 38 while creatinine is normal at 1.0, giving a BUN-to-creatinine ratio out of proportion and typical of an upper GI source, and his INR is normal at 1.1.
My leading diagnosis is upper GI bleeding, most likely peptic ulcer disease related to his NSAID use, supported by the melena, disproportionately elevated BUN, and anemia. Mallory-Weiss tear and gastric malignancy remain on the differential and should be assessed at endoscopy.
I would stop his NSAID, establish two large-bore IVs, start an IV proton pump inhibitor, send a type and screen, and arrange urgent endoscopy within 24 hours along with a standing surgical consultation. I would calculate a Glasgow-Blatchford score to guide urgency and disposition.
Build the presentation
Give every sentence one job
A presentation is a compressed clinical argument, not a chart read aloud. These six moves keep the facts connected to your reasoning.
Opening one-liner
Name the bleed, its duration, and the orthostatic symptom
“Mr. Nguyen is a 45-year-old man on daily NSAIDs for osteoarthritis who presents with two days of black, tarry stools and dizziness on standing.”
Why it belongs: Naming the NSAID use and the orthostatic dizziness together in the opening sentence signals both the likely cause and the severity of blood loss before any lab value is given.
This is a 45-year-old with black stools.
Mr. Nguyen has two days of melena and dizziness on standing, and takes daily NSAIDs for osteoarthritis.
Why: Connecting the NSAID use and the orthostatic symptom in one sentence gives the listener both the likely cause and the severity signal immediately.
History of present illness
Give the specific bleeding pattern and relevant negatives
“He has had three episodes of melena over two days with mild epigastric discomfort but no vomited blood and no bright red rectal bleeding. He wonders if it could be from iron-rich food but is frightened it might be cancer.”
Why it belongs: The absence of hematemesis and bright red bleeding helps localize this to an upper source without massive ongoing hemorrhage, and naming his cancer fear allows it to be addressed directly later.
He's had some dark stools and stomach discomfort.
He has had three episodes of melena over two days with mild epigastric discomfort, no hematemesis, and no bright red rectal bleeding.
Why: Naming the specific negatives is as diagnostically useful as the positive findings.
Relevant background
Quantify the NSAID exposure and other history
“He takes ibuprofen three times daily for six months for osteoarthritis and recently started omeprazole; he has no prior GI history, works as a chef, and drinks alcohol only occasionally.”
Why it belongs: Quantifying the dose and six-month duration of NSAID use is what actually establishes the risk, rather than simply noting that he takes an NSAID.
He takes ibuprofen for his joints.
He takes ibuprofen three times daily for six months for osteoarthritis.
Why: The specific dose and duration establish the level of risk more precisely than a general statement.
Objective data
State the labs that support significant upper GI bleeding
“His hemoglobin is 9.1, his blood urea nitrogen is elevated at 38 while creatinine is normal at 1.0, giving a BUN-to-creatinine ratio out of proportion and typical of an upper GI source, and his INR is normal at 1.1.”
Why it belongs: A BUN disproportionately elevated relative to a normal creatinine is a recognized pattern in upper GI bleeding from digested blood protein, and a normal INR confirms this is not related to anticoagulation.
His blood counts and kidney numbers are a bit off.
His hemoglobin is 9.1, BUN is 38 with a normal creatinine of 1.0, and INR is 1.1.
Why: Exact values and naming the BUN-to-creatinine pattern let the listener judge the evidence for an upper source.
Assessment
Commit to the likely cause and rank alternatives
“My leading diagnosis is upper GI bleeding, most likely peptic ulcer disease related to his NSAID use, supported by the melena, disproportionately elevated BUN, and anemia. Mallory-Weiss tear and gastric malignancy remain on the differential and should be assessed at endoscopy.”
Why it belongs: The assessment commits to the most likely cause based on the NSAID exposure and lab pattern, while naming the alternatives that endoscopy will need to specifically evaluate for, including his feared diagnosis of cancer.
This is probably an ulcer from his ibuprofen.
This is most likely peptic ulcer disease related to NSAID use, though Mallory-Weiss tear and gastric malignancy remain on the differential.
Why: Naming the alternatives, including malignancy, shows the reasoning is not closed prematurely.
Plan
Sequence NSAID cessation, resuscitation, and endoscopy
“I would stop his NSAID, establish two large-bore IVs, start an IV proton pump inhibitor, send a type and screen, and arrange urgent endoscopy within 24 hours along with a standing surgical consultation. I would calculate a Glasgow-Blatchford score to guide urgency and disposition.”
Why it belongs: Stopping the causative NSAID is a simple but essential step often omitted, and sequencing resuscitation before endoscopy reflects safe, guideline-consistent management.
I'll start a PPI and get GI to scope him.
I would stop his NSAID, start IV access and a proton pump inhibitor, and arrange endoscopy within 24 hours with surgery on standby.
Why: Naming the NSAID cessation explicitly addresses the root cause, not just the bleeding itself.
Do not fill the blanks
Say what has not yet been established
Real presentations often happen before the chart is complete. A brief, explicit limitation is safer and more credible than a polished invention.
Vital signs, including orthostatic measurements
Say: “Vital signs, including lying and standing blood pressure, are not documented in this simulation, and I would check them immediately given his reported dizziness on standing.”
Orthostatic vitals directly quantify how much blood volume has been lost.
Type and crossmatch result
Say: “A type and crossmatch result is not yet available in this simulation and should be confirmed before any transfusion is needed.”
Transfusion decisions depend on both the hemoglobin trend and confirmed compatible blood being available.
Clinical compression
What leads, what stays, and what can wait?
| Source detail | Decision | Reason |
|---|---|---|
| Two days of melena with dizziness on standing | Lead | This defines the acute bleeding problem and its hemodynamic significance. |
| Ibuprofen three times daily for six months | Lead | This quantifies the NSAID exposure that most likely caused the ulcer. |
| Works as a chef, occasional alcohol | Omit | This detail does not change the immediate bleeding management. |
| Fear that this could be cancer | Compress | Worth a brief mention since it should be addressed directly, but it should not slow down the urgent history. |
| BUN of 38 with a normal creatinine of 1.0 | Lead | This pattern is specific supporting evidence for an upper, rather than lower, GI source. |
After the presentation
Likely attending questions
Answer the question first, then give the evidence. If the source case does not contain the answer, say what you would verify.
Why is his BUN elevated when his creatinine is normal?
Digested blood protein in the upper GI tract is absorbed and metabolized to urea, so a disproportionately elevated BUN relative to a normal creatinine is a recognized supporting clue for an upper, rather than lower, GI bleeding source.
Should you transfuse him now?
That depends on his hemodynamic status and hemoglobin trend, which are not fully available in this simulation; a restrictive transfusion threshold, generally around a hemoglobin of 7, is typical, but his orthostatic symptoms need urgent evaluation first.
How urgently does he need endoscopy?
Endoscopy is generally recommended within 24 hours of presentation once he is adequately resuscitated; timing also depends on his ongoing hemodynamic stability, which still needs to be confirmed.
Self-check
A 30-second check before you present
- Name the NSAID use and the orthostatic dizziness together in the opening sentence.
- Quantify the NSAID dose and duration, not just 'takes ibuprofen.'
- State the specific negatives: no hematemesis, no bright red bleeding.
- Give hemoglobin, BUN, creatinine, and INR with exact values.
- Name the BUN-to-creatinine pattern as supporting evidence for an upper source.
- State that the NSAID is being stopped, not just treated around.
- Give the resuscitation and endoscopy-timing plan together.
- State what vital signs, especially orthostatic measurements, are still needed.
Common presentation problems
Repair the habits that make a case hard to follow
Reporting a low hemoglobin without checking orthostatic vitals
Repair: State that lying and standing blood pressure still need to be checked given his reported dizziness.
Treating the bleed without stopping the causative NSAID
Repair: State explicitly that the NSAID has been stopped.
Omitting the BUN-to-creatinine pattern
Repair: State both values and name the pattern as supporting evidence for an upper source.
Delaying endoscopy discussion until asked
Repair: State the planned endoscopy timing as part of the initial plan.
Frequently asked questions
Oral case presentation questions
Should I mention the Glasgow-Blatchford score explicitly?
Yes, mentioning that you are calculating it shows you are using an objective tool to guide urgency and disposition, even if you do not recite every component.
How do I address his fear of cancer without overpromising?
Acknowledge the concern honestly and state that endoscopy will directly assess for malignancy along with the more likely ulcer diagnosis, without promising a specific result before the test is done.
How long should this presentation be?
This worked example targets about 80 seconds. A hemodynamically unstable patient would need a shorter, more urgent initial presentation focused on resuscitation.
Practice out loud
Turn the patient encounter into your own presentation
Bedside English lets you interview an AI patient, then practice presenting the collected case to an AI attending and respond to follow-up questions.
Editorial record
Sources, provenance, and review boundary
The patient facts come from simulated case gi_001. Clinical framing and presentation design were checked against the sources below. This page teaches clinical communication and reasoning; it is not medical advice or a local protocol.
- ACG Clinical Guideline: Upper Gastrointestinal and Ulcer BleedingAmerican College of Gastroenterology · accessed 2026-09-03
- Feedback on Oral Presentations during RoundsStanford Medicine · accessed 2026-09-03
- Clinical Teaching Tools: OMP and SNAPPSUCSF Medical Education · accessed 2026-09-03
Published: · Last source, safety, and language review: