Case of the Week
A 49-year-old man with a history of hypertension presents to the ED feeling weak
and complaining of “black vomit” and “black diarrhea” for the past several
days.  He has no history of dyscrasia; he takes aspirin “from time to time”.  The man reports no other medications, herbal remedies, or over-the-counter preparations. 
He is elusive about his drinking history, later remarking that he drinks beer once or twice a week; however, when he does he describes drinking a ‘six-pack at a time’.

On examination, HR 90 BP 110/70 RR 28 SpO2 98% RA.  He is slightly anxious, but able to cooperate with the history and physical examination.  His pulmonary and cardiovascular exams are normal; abdominal exam shows no mass or tenderness; he has melena on rectal exam; skin signs are normal.

This man’s hemoglobin is 10.1 g/dL; on chart review it was 14.3 g/dL one year prior.

You suspect an upper gastrointestinal (GI) bleed in a relatively stable patient and
you treat him with gentle fluids, NPO, and a proton-pump inhibitor.  His repeat examination, vital signs, and hemoglobin are unchanged.  You call the admitting team who requests a nasogastric tube (NGT) aspirate “to see if GI needs to come down now or if he needs the ICU”.

You identify an opportunity to discuss the utility of an NGT in this case.  Of the many points that could be made in the discussion, which of the following is TRUE:

    A. The NGT aspirate can rule out an upper GI source
    B. The NGT aspirate predicts morbidity or mortality
    C. The NGT is necessary to clear contents for the endoscopy
    D. The NGT is not necessary to diagnose an upper GI bleed

In the meantime, a few quotes – 
“It was a lie but he believed in telling lies to people. Truth telling and medicine just didn't go together except in dire emergencies, if then.”
― Mario Puzo, The Godfather


"Declare the past, diagnose the present, foretell the future.” 

― Hippocrates


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